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serenavangstuff · 5 years ago

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Juniper Publishers-Social Network and Support, Self-Rated Health, and Loneliness as Predictors of Risk for Depression Among pre-Frail and Frail Older People in Sweden

Abstract

Introduction: Family and social network are indispensable to the well-being of the older people. However, little has been documented about benefits of the social network and support in reducing the risk for depression among older persons in Sweden. This study aims to examine the relationship between social network and social support, loneliness, and self-rated health among older Swedish people and to determine the ability of these variables (and personal characteristics) to predict the risk for depression among pre-frail and frail older people.

Methodology: This study analysed aggregated data from three randomised controlled studies, which included pre-frail and frail older Swedish adults age 65 years and above. Analyses were done using chi-square, ANOVA, and multiple regressions (in Stata v14).

Results: Findings from the analysis revealed that out of 737 respondents included in this study, 27.5% were at risk for depression (CI: 24.31, 30.78), 54.8% were living alone and 12.5% had no children. Furthermore, factors that statistically predicted the risk for depression include having a confidant (β=1.32, p;=0.006) loneliness (β=11.47,p=0.000, self-rated health (β=-2.60, p=0.000), changes in loneliness (β=-10.16, p=0.000), number of children (β=0.78, p=0.000), number of confidant (β=-0.19, p=0.068) and living alone (β=-0.61, p=0.005).

Conclusion: This study concluded that a large number of the older adults in this population is at risk for depression and factors that predict risk for depression include having a confident, living-alone, number of children, loneliness and poorer self-rated health. Therefore, health- promoting activities that encourage interaction and communication among the older adults should be implemented to promote their well-being.

Keywords: Confidant, community-dwelling, living alone, older adults, well-being

Abbreviations: EPRZ: Elderly People in the Risk Zone; PAMC: Promoting Aging Migrants' Capabilities; GDS: Global Depression Scale; ADL: Activity of Daily Living; MMSE: Mini Mental State Examination

Introduction

Social network and support are indispensable to the wellbeing of the older people. O’Caoimh, Cornally [1] opined that caregiver networks are a central component in the management of frail and functionally impaired community-dwelling older adults. Social networks can be defined as the web of identified social relationships that surround an individual and the characteristics of those linkages [2,3]. It is the set of people with whom one maintains social contact or some form of social bond that may offer help or support in a variety of situations [2,3]. Social support refers to the perceived available resources from people who individuals trust and on whom they can rely [4]. It is related to individual's perceptions of the degree to which social relations offer different forms of resources (functions) such as material aid or emotional support [2] Benefits of social support and networks have been linked empirically to a number of positive social and psychological outcomes [5]. Results are consistent with the hypothesis that lower reported social support is an important reason for increases in depressive symptoms found among older adult populations [6]. Social support and social networks are also among the psychosocial influences of physical and mental well-being [7].

On the other hand, the consequences of absence of social support has been associated with poorer mental health and reduced cognitive performance, and objective social isolation [8], poorer mental health performance [9], declining health, loneliness [10], and mortality [11]. It also includes the risk of institutionalization and mortality of older persons [12]. However, Chappell and Badger [13] observed that living alone or having no children, and many measures of social isolation are not related to well-being.

As a person increases in age, the ability of systems in the body to perform their basic functions deteriorate and frailty set in [14]. Frailty refers to a multi-system deterioration of the reserve capacity at older ages, resulting in increased vulnerability to stressors [15]. Similarly, pre-frailty is defined as having less than three of five physical frailty criteria (low grip strength, low energy, slowed walking speed, low physical activity, and/or unintentional weight loss) [16]. This often necessitates the need for support from a significant person who might be their children, relatives, friends or governmental and non-governmental agency.

The availability of a significant member of the family may not be a guarantee that there will be an improvement in the wellbeing of the elderly. There are possibilities for an older adult to be suffering in the midst of plenty. It has been argued that people must have connections with other people (network) in order to receive social support, but social connections do not guarantee access to social support. Similarly, the ability of social support and network to mitigate the impact of living alone, poor health and loneliness on the risk for depression has not been explored among the pre-frail and frail older persons in Sweden. Efforts geared towards investing social network and support will have a multiplying effect on the health promotion of the older people.

Among the Swedish population, the number of older persons without children is on the increase; similarly, many of these older adults are living alone. This may be associated with childlessness or those whose children have already left home. This phenomenon makes them at risk for social isolation and loneliness and its consequences such as poor psychosocial well-being including risk for depression. However, it has not been well-established if living alone automatically translates to loneliness and the risk for depression among this population. The effect of modifiers such as social networks and social support may be at play. Seeking to support the advancement of knowledge on this subject, this study examined the influence of social network and support, self-rated health, and loneliness on the risk for depression among pre-frail and frail older persons aged 65 and over in Sweden. We thereby hypothesised that social network and support, self-rated health, and loneliness will not predict the risk for depression among the older adults.

Methodology

In this secondary analysis, we used baseline data aggregated from three randomized controlled trials namely: the Elderly People in the Risk Zone EPRZ [17], Continuum of Care for Frail Elderly People [18], and the Promoting Aging Migrants' CapabilitiesPAMC [19]. The three studies received ethical clearance from the Regional Ethical Review Board in Gothenburg. The protocol numbers are as follows: EPRZ (# 65007) Continuum of Care for Frail Elderly People (#413-08), and PAMC (# 821-11). Written informed consent was obtained from the participants.

Participants and Setting

The settings for the three studies were selected urban districts in a large city in western Sweden. The urban districts represented regions with high, middle and low socioeconomic parameters (e.g. general income level, sickness rate), and contained a mix of self-owned houses and apartment blocks. The population for the study comprises a representative sample of pre-frail and frail community-dwelling older adults 65 years to 99 who lived in ordinary housing and are either independent or dependent in Activity of Daily Living (ADL). The selection for EPRZ and PAMC took a similar pattern [20,21]. Participants in EPRZ and PAMC were randomly selected from the official registers in the urban district and were invited to participate in the study either through a letter and a telephone call. During the call, selected individuals were informed verbally about the study and given the opportunity to ask questions if anything was unclear. They were also asked personally if they would like to participate in data collection. Likewise, participants of the Continuum of Care study were recruited from the emergency department at Molndal Hospital and were followed-up to their home for data collection [22] in order for the sample to represent different levels of frailty. In addition, the PAMC included persons who migrated from any of the selected European countries (Finland and the Western Balkan region) and were residents in Sweden before the period of data collection [17-19]. All participants were cognitively intact with a score over 80% of Mini Mental State Examination (MMSE) [23].

The original study population comprises EPRZ: 459 persons, Continuum of Care: 161 persons, and PAMC: 131 persons, which gave a total of 751 participants. However, only 737 participants who had complete data on selected variables were used in the analysis of this study.

Data Collection

The studies were conducted as follows: EPRZ (2007 to 2011), Continuum of Care (2008 to 2011), and the PAMC (2012 to 2016). Baseline data from all three studies were used for the present study. All data were collected by trained research assistants (Occupational therapist, Physiotherapist, Registered nurse or Social worker) using a face-to-face approach in the participant's home or in another place if the participant wished. The items and the response alternatives were read to the participants and, if needed, shown on a paper. The research assistants were proficient in the languages spoken by the participants and were trained in interviewing, assessing and observing, according to the guidelines for the different outcome measurements. To ensure standardization of the assessments, study protocol meetings were held regularly throughout the periods of data collection.

Instruments for Data Collection

In all the studies, data were collected using a comprehensive interviewer administered questionnaire, which contained all the variables such as risk for depression, a number of children, confidants, and self-rated health. The instruments were written in participants' mother tongue.

Demographic Variables

Five demographic characteristics were used in this study. These include age, gender, level of education, profession before retirement, and living arrangement (living alone or not) (Figure 1).

Independent Variables

Social network: This is defined as a set of individual family members, relatives or friends who are present around an older person and there is an exchange of physical, financial or emotional resources between them. In this study, the social network was measured by the following variables: having children, number of children, distance to children, confidant (someone to trust), the number of confidants. Item on children was rated as yes or no, participants were asked on the number of children they have. Similarly, participants were asked to state the distance to their closest child. In addition, they were asked whether they have anyone to trust or confide in (confidant) and to state the number of those people (Figure 1).

Social support: Social support refers to the individual who an older person turns to for physical, financial or emotional help or assistance. This was assessed by asking participants a question on the source of help and it was assessed using an item questions asking who do they turn to when ill, when they need practical help, when they need advice or when they need to talk about personal troubles. Options range from (a) Husband / wife / partner (b) Non-cohabitant partner (c) child (d) Other relatives (e) Neighbours (f) Friends (g) Home care /nursing care, (h) Voluntary organization and others (i) and have no one to turn to. These were grouped into three categories representing how close they are to the old person. These categories are: Category One represents the closest source of help and it comprises (a) Husband/wife/partner (b) Non-cohabitant partner and (c)Children. Similarly, Category Two, representing a closer source of help. This includes other relatives (e) Neighbours (f) Friends. The third category represents the professional or paid assistance or non-governmental organization which includes (g). Home care / nursing / or Voluntary organization.

Self-rated health was measured by a single item asking respondents to rate their health on a 5-point scale. The options are Excellent, Very good, Good, Fairly and Bad [24]. Any individual with excellent, very good and good was categorised as good self-rated health while anyone who choose fairly and bad was categorised as poor self-rated health.

Loneliness is a subjective assessment and relates to individuals' perceived levels of isolation and satisfaction with existing relationships [25]. It was assessed using an item which asked the respondent to state whether they were lonely or not based on the following options: No, never, Yes, rarely, Yes sometimes, and Yes, often. The "no" option represents the absence of loneliness and the "yes" options were grouped together to signify the presence of loneliness. This was also followed by a question that asked if they were lonely more than ten years ago. Responses were Yes, more, No difference and No, less.

Dependent Variable

The risk for depression was measured with the aid of the Global Depression Scale (GDS)-20 [26]. The GDS is a 20-item selfreport scale measuring supposed manifestations of depression with yes or no option representing 1 and 0 respectively with a total score ranging from 0 to 20. The score for depression as measured by the GD20 ranges from 0 to 20 and a cut-off point for risk for depression was 5 [27]. Persons with a score above the cutoff point are regarded as having the risk for depression.

Data Analysis

Descriptive analyses were conducted using frequency and percentage to understand the characteristics of the study sample. In addition, chi-square and one-way analysis of variance (ANOVA) with Bonferroni adjustments for multiple comparisons was conducted to determine the association between each of the independent variables [social network (children, number of children, number of confidant, confidant), and social support (source of support), loneliness, changes in loneliness, and selfrated health] and all covariates (older people characteristics including age, gender, profession, education and living alone) to find significant indicators (used a level at 0.05) on the dependent variable (risk for depression). Furthermore, forward stepwise multiple regression analysis was conducted to determine the predictive effect of the independent variables on the risk for depression. All the independent variables, as well as covariates, were included in the model. All analyses were performed using STATA14 statistical software (Stata Corp, USA)

Results

The age of the respondents ranges from 65 to 97 with a mean of 81.34 years (±6.4). The median age was 82 years and 72.5% of participants were within the age 80-89 categories. There was a preponderance of female participants (59.7%) to male. It also revealed that 27.5% had elementary school level or lower and that 50.3% were white collar workers before retirement (Table 1).

Findings from the analysis revealed that out of 737 respondents included in this study, the mean score for depression in this study was 3.79 and 27.54% (95% CI: 24.31, 30.78) were at risk for depression. A bivariate analysis was conducted and the following factors were significantly associated with risk for depression among the older people: Age (p = 0.000), living alone (p = 0.000), profession (p = 0.000), confidant (p = 0.000), the number of children (p = 0.000), source of support (p = 0.000), self-rated health and loneliness (p = 0.000). However, education, gender, and having children and were not significantly associated with risk for depression (Table 2).

A multiple regression was conducted to test the predictive effect of demographic and social network variables the following independent variables: Age, sex, living alone, number of children, distance to children, having a confidant or someone to trust, number of confidant, loneliness, and changes in loneliness over the years, and sources of support when ill. In the analysis, distance to children was omitted because on colinearity with children. Using a stepwise regression method, it was found that the independent variables explain a significant amount of the variance in the value of risk for depression, F (13, 723) = 40.18 p <.000, R2 = 0.42, R2Adjusted = 0.41)]. These variables: Confidant (β=1.32, p=0.006), loneliness (β=11.47, p=0.000), self-rated health (β=-2.60, p=0.000), changes in loneliness (β=- 10.16, p=0.000), number of children (β=0.78, p=0.000), number of confidant (β=-0.19, p=0.068), living alone (β=-0.61, p=0.005) significantly predicted the risk for depression (Table 3).

Discussion

Findings from this secondary analysis revealed that 27.5 % of the pre-frail and frail older adults above 65 years in Sweden are at risk for depression. In addition, variables that predict risk for depression include having a confidant, loneliness, self-rated health, changes in loneliness, number of children, number of confidants, and living alone.

Findings from this study underscore the inestimable contributions of the social network and support to the wellbeing of the older adults. Social network and support have a direct correlation with risk for depression. Similar findings have been observed by Santiago and Mattos [28] and Litwin [29] who documented that social support provision was positively associated with subjective health among Arab-Israelis. The presence or absence of a significant person around an individual will subsequently positively influence the risk for depression among the older adults.

Findings from this study also revealed that having children is a protective factor against the risk for depression among the older people. This is in consonant with Herman-Stahl, Ashley [30] who concluded that those who remain childless are indeed faced with lower levels of psychological well-being, as compared to parents who live with children and people whose children have already left the parental home. This is also supported by Chou and Chi [31] submission that childlessness is a stronger and more consistent risk factor for psychological well-being such as loneliness and depression in Chinese older adults. Furthermore, Carayanni, Stylianopoulou [32] observed that being childless was associated with the prevalence of depressive symptoms among women. This is however contrary to the finding from a previous study Zhang and Hayward [33] who posited that childlessness per se did not significantly increase the prevalence of loneliness and depression at advanced ages, net of other factors. Having someone to talk to or confide in seems to be a protective factor against risk for depression among the older people in this study than having children. Findings from this study revealed that having a confidant or someone to talk to was significant in predicting the risk for depression. The implication of this is that ability to find someone to talk to or confide in is more important to the well-being of the older people who may not necessarily be their offspring. This may be related to the kind of family structure that exists in this study population whereby, older people are living alone without any of their children or relatives around them. This finding further stresses the need to promote communication and interaction through health-promoting intervention for the older adults.

The number of numbers of connections and networks (children and friends) is also important to the well-being of the older adults. This suggests that there may be strength in the quantity of the network. This is supported by Rosenquist, Fowler [30] who reported that people who have a significantly worse score on the Center for Epidemiological Studies Depression Scale also have fewer friends. Similarly, a study by Ross and Mirowsky [31] also showed that social connection decreased depression among the participants in their study. Further scrutiny of the source of support revealed that friends and other relatives contribute significantly to the well-being of the older people. This finding emphasises the importance of social connection and support for the older people which may not necessarily come from the children or immediate family, but from those whom they are interacting with. This may also explain the difference in the family structure and support system for the older people in Europe and in some developing nations such as Africa and Asia.

Among the African and Asian communities, the care and support for older people are hinged upon the family members. Children play a significant role in the care of the older adults. This situation is different in this study population. Having children was not significantly related to the outcome variable (risk for depression). Compared to the African or Asian where older adults live within the extended traditional family system, in this study population, older adults live on their own. The risk of living alone would even be more among those who have lost their partners.

Furthermore, the number of children is important in the model. Having up to four children was associated with the outcome variable. It was protective for the risk of depression. It is important to point out that the sample population comprised a mixed group. The immigrant's Swedish residents are generally different from the indigenous one in regard to family size. Unlike the native who typically have one or two and quite a good number did not have any child. The immigrants tend to have more, although, most of these migrants have lived in Sweden for more than 20 years, they have a higher tendency to have more children compare to the native. The proportions of migrants with more than four children almost double the original native (6.8%: 11.2%) [19].

Therefore, efforts to improve health and well-being among the older adults not only must address the consequences of illness and disease but must also attend to older adults' social connections. This may be inevitable owing to the unprecedented reduction in the fertility rate facing most European nations. In addition, interventions to increase participation in social activity among the older people, such as health-promoting initiatives, should be given a priority.

This study indicated that a substantial number of the prefrail and frail older adults in Sweden are at risk for depression. Although, the prevalence of depression in this population is lower than what was obtained from other studies conducted among institutionalised older adults [28,32,33], it is however, higher than the estimates expected from community studies which is put at between 11.5% and 13.5% [34,35]. This high prevalence may be related to the presence of risk factors such as loneliness, poor self-rated health, living alone and others that have been shown to be statically correlated with depression. Considering the high rate of risk for depression in this population together with its associated risk factors, it must, therefore, be considered a major problem that warrants urgent attention. Furthermore, Goosby, Bellatorre [36] declared that depressive symptoms were a conduit through which loneliness influenced certain health outcomes. These authors further stressed that there is a strong connection between depressive symptoms, poor self-rated health, and loneliness.

Self-rated health is also a strong predictor of overall wellbeing and mortality, and it is highly correlated with depression [36]. One possible reason for this is that the advanced age may be associated with decreased functional capacity, a decrease in social activities and illness symptoms and hence, the older adults may perceive and rate their health as being poor, and this might place them at a risk for depression. Besides, all the participants in the continuum of care project were individuals with at least one chronic illness, which suggests poor health. Results from this research suggest that much work is needed to reduce illness and promote the health of older people.

Findings from this study have also shown the predictive effect of living alone on the risk for depression among the older persons. This supports Lim and Kua [37] who reported that the depression score was associated with living alone among the older persons in Singapore. Similarly, studies by Cheng, Fung [38], Chou and Chi [39] also reported that older persons living alone were more likely to be depressed. Living alone may engender social isolation especially among those with limited social contacts thereby predisposing to more depression [40]. However, this is contrary to some authors who reported that living alone was not associated with higher levels of depressive symptoms [41,42]. This contrary opinion may be related to the fact that although a person may be living alone, but may not benecessarily isolated. The person may be remotely engaged in social interaction and other activities that mitigate the effect of social isolation.

In view of the ability of social connection and support to mitigate the negative consequences of the major health problems in this study, the effort geared towards promoting interaction, as well as provision and receipt of support from friends and relatives of the older adults will go a long way in improving the well-being of our older people.

The main limitation of the study is related to the self-report nature of the information provided during data collection and these were not objectively and clinically validated, and there might have possibly led to some bias. However, findings from this study provide significant insights into the interplay of invaluable contribution of the social support and network to the well-being of the older adults in Sweden and other countries with similar settings.

Conclusion

This study concluded that risk for depression is highly prevalent among pre-frail and frail older adults above 65 years in Sweden. It also concluded that having a confidant rather than having children is important to mitigating the consequences of risk for depression among the older adults. In addition, loneliness, poorer self-rated health, and living alone are some of the factors that predict risk for depression. Therefore, activities that promote interaction and communication among the older adults should be encouraged. This could also be useful for early identification and treatment of older people with the risk for depression, which is highly prevalent in this population.

Key Points

a) The risk for depression is highly prevalent in pre-frail and frail older adults above 65 years in Sweden.

b) Having a confidant (social connection) rather than having children is important to the well-being of the older adults.

c) Loneliness, living alone, a small number of children, and poor self-rated health are predictors for risk for depression.

d) Having a large number of networks and connections are important to the well-being of the older adults.

Acknowledgement

"This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Wellcome Trust (UK) (Grant No: 087547/Z/08/Z), the Department for International Development (DfID) under the Development Partnerships in Higher Education (DelPHE), the Carnegie Corporation of New York (Grant No: B 8606), the Ford Foundation (Grant No: 1100-0399), Google.Org (Grant No: 191994), Sida (Grant No: 54100029) and MacArthur Foundation Grant No: 10-95915-000-INP".

Conflict of Interest

The authors declared no conflict of interest.

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serenavangstuff · 5 years ago

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Juniper Publishers-Postural Control in Patients with Respiratory Dysfunctions: A Systematic Review

Abstract

Objective:To identify the main methods of intervention by means of exercises through postural control for COPD and asthmatic patients and their beneficial effects.

Methods:A systematic review was performed to identify which postural control treatment should be applied in these cases. The following bibliographic databases were consulted: PubMed, Bireme and Science Direct. Clinical trials involving techniques for postural control and that compared the results analyzed in the pre and post intervention period.

Result: The electronic search yielded a total of 2113 references published in any language, of which only 7 met the criteria for inclusion and exclusion.

Conclusion:Broadly, the age bracket above 50 years was observed in 6 out of the 7 studies; resistance training in 3 out of 7 studies; vibratory platform training in 1out of 7 studies; postural control training associated with breathing in 3 out of 7 studies and clinically significant improvement in intervention in 3 out of 7 studies, demonstrating a variety of treatment techniques making it difficult to produce a higher level of evidence.

Keywords: COPD; Respiratory; Asthma; Postural Muscle; Postural Control

Abbrevations: COPD: Chronic Obstructive Pulmonary Disease; WHO: World Health Organization; COLD: Chronic Obstructive Lung Disease; UN: United Nations; ABC: Activities Specific Balance Confidence scale; TUG: Time Up and Go; BBS: Berg Balance Scale; SGRQ: St George’s respiratory questionnaire; RS: Romberg stance ; STEC: SemiTandem Stance ; STEO: Semi Tandem Stance; OLS: One Led Stance; CRQ: Chronic Respiratory Questionnaire; TOC: Oxygen Cost Diagram; VAS: Visual Analogue Scale; MVV: Minute Volume ; FVC: Forced Vital Capacity; 6MWT: 6-Minute Walk Test

Introduction

Respiratory dysfunctions affect a large part of the world’s population. Among them, two have a prominence and are studied by the World Health Organization (WHO) and by researchers in much of the world. Chronic Obstructive Pulmonary Disease (COPD), according to the Global Initiative for Chronic Obstructive Lung Disease (COLD), may be defined as a preventable and treatable disease [1]. The COPD is a progressive lung disease and a leading cause of morbidity and mortality in Canada [2]. It is also identified as one of the leading causes of death in the world. Data from the World Health Organization (WHO) and the United Nations (UN) estimate 3 million deaths / year. The Canadian health care system estimates an annual average spending of $1.5 billion [3]. The second dysfunction is asthma. The WHO estimates that 235 million people currently suffer from asthma. Asthma is the most common non communicable disease among children [4]. Today, the impairment in patients with pulmonary diseases goes beyond respiratory changes, delivering many other extra pulmonary consequences [5], as is the case with postural control. The systematic review on postural control in COPD, with studies involving the vast majority of control groups [6] concluded that COPD patients have postural control deficits when compared to healthy groups with combined ages. It is known that intervention in respiratory dysfunctions is aimed at reducing pulmonary disturbances, but especially the extra pulmonary disorders. Considering the spine, thoracic cavity and large muscle groups as fundamental to control the sensation of dyspnea, reducing ventilatory work, intervention improves pulmonary volumes and capacities, postural control and minimizes the effects of disuse with the progression of these diseases [7]. But what would be the best intervention methodology? Thus, this systematically review focuses on the literature concerning to identify the main methods of intervention of the last 7 years, with the use of postural control for COPD and asthmatics patients and their beneficial effects.

Materials and Methods

In the present study, a survey was performed on the PubMed, Bireme and ScienceDirect databases. Studies were selected after defining the DeCS and MeSH search terms, such as asthma, postural control, COPD, postural muscles, respiratory. These terms were crossed via Boolean switch statements (AND), as shown in the following topics:

a) Respiratory and postural control and postural muscle;

b) COPD and postural control and postural muscle and respiratory;

c) Asthma and postural control and postural muscle and respiratory;

d) COPD and respiratory and postural muscle;

e) Asthma and respiratory and postural muscle,

Including titles published from January 2010 to October 2017. Initially, four reviewers (YS, DB, GW, FB) independently assessed all selected titles (n = 2113), analyzed their abstracts based on inclusion criteria defined for the study: a clinical trial involving techniques for postural control and comparing the results analyzed in the pre- and post-intervention period. From this sample the following articles were excluded: those published in the form of abstracts, those that only evaluated the subjects and did not treat, those that only compared between healthy groups and with respiratory dysfunction without intervention and the articles relating the postural control only with the risk of falls. Duplicate items were also omitted (Figure 1). The full texts of the potentially relevant articles were retrieved for final evaluation, and their reference lists were independently checked again by the same reviewers to identify studies of potential relevance not found in the electronic search.

Result and Discussion

This review provides an important summary of the main available methods of intervention in postural control for patients with COPD and Asthma, indicating the need for more work. Of all the articles included in this review, there are variations of postural control techniques for patients with respiratory dysfunction. Among them are: the time of intervention, in some cases 30-45 min, another 80 min. Such studies ranged from 3 to 12 weeks, 3 to 6 times per week. In addition, some studies have applied gait training; others exercise bike with stipulated speed and other exercise bike with free speed, with low and high intensity of training. Also, resisted exercises with weights or elastic bands, with load defined by 10 RM, free load or by challenges as the intensity supported by the patient, with 10 repetitions or with 15 to 20 repetitions. Traditional exercises or with the use of technological resources such as indicators of postural stability. Balance and coordination exercises. Stretching and relaxation, cognitive tasks. Exercises of diaphragmatic breathing and with closed lips. To finish oriental technique like Tai Chi. This reflects the fragility of the levels of evidence offered by the literature to support these different intervention methodologies (Table 1).

Beauchamp et al. [8], used supervised resistance training in COPD patients 4 to 5 times a week using 6MWT as baseline, each patient received an individualized program of 60% to 80% of the average speed achieved during 6MWT (for treadmill exercise or walking) or 60% to 80% of the VO2max estimate of 6MWT for bicycle training, periods of high intensity exercise were alternated with rest periods (3 min at 80% VO 2 max alternating with 2 min of relative rest). The duration of the exercise progressed until patients could tolerate 20 to 30 minutes of resistance exercise at the most tolerated symptoms level, after which the speed or intensity increased from 10% to 20%. Strength training for upper and lower limbs (3 times per week) included the following lower limb muscles: quadriceps, hamstrings, hip flexors, hip abductors, and hip extensors. The exercises were completed in seated and standing positions with the use of ankle weights for endurance. The training for upper limbs included the muscles, biceps, triceps, pectorals and deltoid using an elastic resistance band. The amount of resistance provided was based on the patient’s ability to complete 15 to 20 replicates [9-11]. Patients received a daily 30-minute class that included stretching in major muscle groups and instructions on diaphragmatic and puckered respiration of the lips. Self-management education and psychological and social support were provided through lectures, relaxation classes and recreational activities at least twice a week for 30 minutes. In a recent study by Gloeckl et al. [12] strength training (15 minutes of cycling at 60% of peak energy) and strength training (four to six exercises on strength training machines with three sets of 15- 20 repetitions for major muscle groups using maximum load. In addition, all patients underwent a supplementary program with squatting exercises on a lateral alternating vibration platform (Galileo®, Novotec Medical GmbH, Pforzheim, Germany) lasting 2 minutes, three Times a week. In general, what varied from one study to the other was: the association between strength and resistance exercises, with association of these elements or chose only to choose strength exercises, in addition, balance exercises were also placed in the intervention program. We used predominantly the following reference tools: ABC (Activities Specific Balance Confidence scale), TUG (TIME UP AND GO), Berg Balance Scale (BBS), St George’s respiratory questionnaire (SGRQ), 6MWT, Romberg stance (RS), semi-tandem stance (STEC), semi-tandem stance (open eyes) (STEO) and one-led stance (OLS). (BESTest), 30-s chair-stand test, PF-10, CRQ (chronic respiratory questionnaire). The ABC scale did not show significant improvement in any of the studies, but the Berg balance scale and the TUG test showed significant improvement in all the studies that used these tests as analysis [12]. In 2016, Bezolli et al. [9] studied participants with obesity, with an age range of around 53 years. An intervention period of 3 weeks was analyzed, with 5 interventions per week, lasting 30 minutes in a group. The intervention was with resistance training using a cycloergometer and specific exercises with the objective of increasing the perception and activation of the lumbarpelvic musculature; world reference evaluative tools such as: Spirometry, 6-minute walk test, chest wall circumference, MIP, MEP, oxygen cost diagram (TOC), visual analogue scale (VAS), and patient functional scale were used.

The experimental group showed significant improvements in functions such as minute volume (MVV), Motley Index and forced vital capacity (FVC). There was no improvement in 6MWT and in the thoracic circumference. The control group presented improvement in 6MWT, thoracic circumference and VAS remained unchanged. The results were beneficial but there is little research on this subject, so it was not possible to compare studies on postural control and improvement of respiratory performance in obese individuals. The study by Marques et al. [10] in COPD patients, applied a warm-up of 5 to 10 minutes, involving range of motion, stretching, low-intensity aerobic exercises and respiratory techniques such as pursed lip breathing, body positions, diaphragmatic breathing, and airways cleaning techniques. After that, resistance training (walking) for 20 minutes with 60% to 80% of the average speed achieved during the 6-minute walk test (6MWT). Strength training (15 minutes) included 7 exercises (2 sets of 10 repetitions) for upper and lower limbs using elastic bands, free weights and ankle weights, and the amount of weight applied was between 50% and 85% of 10 repetitions (10RM). The balance training (5 minutes) mostly comprised static and dynamic exercises using vertical positions and were organized in 4 levels

a) Postures that gradually reduced the support base;

b) Dynamic movements that disturbed the center of gravity;

c) Stress to postural muscle groups; and

d) Dynamic movements while performing a secondary task individually or in groups, with a progressively reduced support base. Finally, 10 minutes rest.

Beauchamps et al. [11] used balance training in four main types of exercise:

a) Posture exercises,

b) Transition exercises,

c) Gait exercises, and

d) Functional strengthening.

When a participant was able to complete a task independently and with little instability, the difficulty level was progressively increased by introducing more challenging conditions (eg, closed eyes, addition of a secondary cognitive task, increase in speed / repetition, or disturbances) Kavocikova et al. [13] analyzed participants with asthma, with an age range of around 11 years. The intervention period was 4 weeks, with 6 per week, lasting 45 minutes in a group. The intervention consisted of: respiratory training with diaphragmatic breathing, pursed lip breathing and thoracic expansion exercises. In addition, children also learned clearance techniques (autogenous drainage and active cycle of breathing techniques), 3 sets of 10 repetitions of each breathing exercise followed by a relaxation of 1 minute pause with controlled breathing. Breathing exercises were also performed in the vertical sitting position in a chair and standing position (bipedal and unipedal conditions) in balance devices (Airex Pad, Soft Gym Overball, Bosi® Balance Trainer PROFI and Original Pezzi® Gymnastik Ball Standard). In physical training: proprioceptive exercises, functional strength exercises (lower limbs, upper limbs and core), hand-eye coordination exercises and resistance training. The evaluation tools were: Postural stability indicator - mediolateral direction (Vx); antero-posterior direction (Vy); and total speed (Vtot). Improvement in Vtot in both positions, Vx in the preferred position and Vy in the adjusted position. After the balance training there was improvement in Vtot in both positions, Vx in the preferred position and Vy in the adjusted position.

Finally, Holmes et al. [14] analyzed participants with a mean age of 70 years in a 12-week intervention period, with 2 interventions per week, lasting 80 minutes in a group, and receiving an instruction DVD of the entire protocol to be performed 20 minutes, 3 times a week at home. The intervention consisted of: warm-up exercises focused on range of motion, incorporating attention and images into movement, increasing awareness of breathing and promoting relaxation of body and mind. Cardiovascular, cognitive, physical and postural control evaluations were performed (stationary force plate with open and closed eyes). The results had a significant effect on all the variables presented, indicating that the collective effect of Tai Chi was different in relation to the educational control intervention. Despite the beneficial results obtained, there was no possibility to compare those with other studies. In this review, we analyzed the effect of postural control on respiratory dysfunctions. We observed that the interventions showed significant improvement, mainly in individuals with asthma and COPD. Regarding the number of studies with interventions, there is still a small amount of articles exploring this topic, many of them not so specific. Generally speaking, this review comprised: age group over 50 years (6 out of 7 studies); resistance training (3 out of 7 studies); vibratory platform training (1 out of 7 studies); postural control training associated with breathing (3 out of 7 studies), and clinically significant improvement in intervention (3 out of 7 studies). Detailing the approach of the clinical trials, we adopted at least one of the evaluation methods below: the Berg Scale (BBS); 6-minute walk test (6MWT) and Time Up Test (TUG); no significant change was found in 6MWT, but with changes in the other tests. The study that presented a larger sample, with the objective of verifying the capacity of exercises in resistance training for individuals with respiratory dysfunctions, presented a significant improvement in the performance of postural control. However, there was no evident significance in the evaluation exercises that also addressed resistance training.

Conclusion

In conclusion, postural control techniques or interventions used in patients with respiratory dysfunctions were more evident in patients with COPD, with a large variety of techniques, but with evaluation methods of recognized quality. There was no demonstration of superiority of one technique when compared to another and in addition, we noticed an extensive methodological variation between the interventions, which hinders the production of a greater level of evidence. Therefore, it is necessary to carry out a larger number of randomized studies involving this population and the intervention techniques.

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Juniper Publishers-Post Discharge Nursing of Older Patients: A Viewpoint in Terms of Reducing Cost of Hospital Readmission

Keywords

Keywords: Post Discharge; Nursing; Older patients; Cost; Readmission

Letter To Editor

As a global health service issue, aging changes quality of life, medicine, economics and ethics of the world [1]. The elderly are more likely than younger persons to suffer from chronic diseases that can cause them to lose their weight, have worsened condition and increased risk of many health problems [2]. Physical deconditioning, functional inability, malnutrition, pressure injuries, put elderly as long stay consumers of hospital care [3].

New health care policies, based on shortened length of hospitalization are a method towards providing elderly with care in their home. Nursing services that provide comprehensive assessment and care in this way are good alternative to sending elderly to hospital. This trend may be more effective for reducing cost of hospital readmission [4].

It is obvious that hospitals are seeking a way to reduce readmissions, improve medication reconciliation, promote patient safety after hospital discharge and promote handovers from the hospital to their home. Improving the discharge process may be done with engagement of health providers and family support in planning follow-up. Yet an area that needs additional exploration is support to caregivers themselves. Patients and their families education for self-care, is a useful trend, but adequately support by caregivers and necessary respite are necessary [5].

Ensure continuity of care and need for support services for the elderly population after they are discharged from hospital is increasing. Therefore, enhanced discharge services by individual care plans and comprehensive geriatric assessment impact on patients and may be beneficial to them [6]. Post discharge interventions may decrease admittance to residential care, length of hospital stay and readmissions; promote clinical outcomes and increase mobility, independence and satisfaction of clients and their families [7].

It is important to identify what discharge interventions are useful for the older patients. These should include assessing their rehabilitation needs, delivering support to them when they would be discharged in the patient's home; however, it should be clear what best intervention is after discharge based on present or their next problems [8].

To conclude, oldness has an important impact on society, its long term complications require a heavy investment of financial resources. Therefore, elderly require an intensive care setting with specialized personnel to provide complex diagnostic and treatment. These services are very expensive in the acute and post discharge phases. On the other hand, the rising hospital financial expenses coupled with a growing old people population decrease the resources of the health care providing, and therefore, a better and long term nursing care is required to save a qualified lives for the old patients after the accident such as myocardial infarction, brain stroke or other chronic diseases and reduce the economic burden of the chronic and irremediable treatment. As key players in the rehabilitation team, the nurses, therefore, should be aware of the post discharge nursing of old patients' aspects in order to promote their recovery.

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Juniper Publishers-The Psychological Harassment Management Process

Introduction

An effective psychological harassment management process occurs when organisations act immediately and instruct designated agents to:

a) Take remedial action

b) Monitor the behaviour of the victim and the perpetrator

c) Analyse the determinants of psychological harassment and

d) Develop Employer Assistance Programs (EAPs).

Remedial Action

According to Bland and Stalcup [1], the remedial action must be determined on a case-by-case basis and commensurate with the gravity of the facts. Remedial action can range in severity from a simple warning to redundancy for unacceptable behaviour. In the Duvin case, the first remedial action consisted of Mr Duvin asking Mr Mache to ‘change his attitude and to show Ms Rex some respect'. It would seem this verbal caution was an insufficient sanction given Mr. Mache continued to berate Ms Rex in his position as supervisor. Without a written warning from the outset, and some specific indication of the repercussions if identified behaviour persists, managers may easily dismiss such verbal warnings - particularly if those managers have the support of senior managers in the organizational hierarchy and no written evidence exists of the alleged behaviours over time.

Bland and Stalcup [1] note it is always helpful to get the victim's desired remedy on the record as early as possible and to implement the desired remedy if it seems appropriate based on the investigation. Mr. Duvin tried to act responsibly in this regard by offering Ms Rex new job responsibilities and a more varied range of job tasks. However, he did not accede to Ms Rex's request for a transfer to another department and thus could not prevent her from experiencing continued acts of harassment.

Monitoring of Behaviour

If after the remedial action both the victim and perpetrator remain employed, the department manager needs to monitor their behaviour on a continuous basis [1,2]. The manager should not only ensure the behaviour of the perpetrator has changed, but also that the person has not been alienated by the investigative process and its outcomes. For this to occur, the perpetrator should clearly understand why their behaviour is unacceptable. This may require the manager to solicit feedback from the perpetrator about the process and where appropriate, to propose appropriate coaching and training [2]. The victim may also need follow-up contacts from HR personnel for several months to ensure the person is satisfied with the decision and is not experiencing any further difficulties.

Analysis of the Determinants of Harassment

Managing psychological harassment requires managers to analyze the determinants of harassment (during and after the investigation) and to change or mitigate them wherever possible. For example, changes to existing recruitment and existing staff appraisal processes may be necessary if the investigation finds these processes have any direct or indirect influence on the identified harassment behaviour. The analysis may reveal poor job/work design exacerbated the situation thus making it more likely for victimization to occur. To create a more healthy work organisation, roles and tasks may need clarifying, and rosters and work schedules made more flexible [4].

Employer Assistance Programs

Victims of harassment may suffer deleterious psychological effects such as social isolation and the loss of self-confidence.These negative states may adversely affect victims' work performance. To counter these negative effects, European organisations assist victims through their EAPS. For example, the Belgium firm Mobistar offers a Team Member Assistance Program (TMAP) with a listening therapist to help victims [5]. The RATP Metro Company (Paris) has created a centre for psychological support for victims of workplace violence (Institut d'Accompagnement Psychologique Post-Traumatique). Here, support is organised on two levels:

a) A hotline for immediate debriefing after a violent incident (this service operates on a 24/7 basis to ensure permanent accessibility)

b) Counselling services including experts on post-trauma treatment.

The Psychological Harassment Prevention Process

When an organization decides to act later, a psychological harassment prevention process needs to be developed and the following measures prioritized [1-6].

Harassment Free Zones

Prevention works best when organizations mandate 'harassment free zones'. For this to happen, every HR department needs to establish a written anti-harassment policy, a written 'zero tolerance' policy prohibiting harassment in general (i.e., sexual harassment, racial harassment) and specifically psychological harassment. For example, the US Department of Defence [1], Volkswagen in Germany, Dupont de Nemours France, Air France, and Lausanne Town Council [5] have written anti-psychological harassment policies. These organisations define the concept, provide practical examples of types of conduct that constitute harassment, and inform stakeholders that such behaviours are unconscionable and perpetrators will be punished (sanctions, redundancy). In France 'La Loi de Modernisation Sociale' mandates an employer to establish a written anti-harassment policy and insert it in the regulations of the firm (Article L122-34 of Code du Travail).

Dissemination of Anti-Harassment Policies

A wide dissemination of harassment policy among employees requires the posting of fliers in prominent locations throughout the workplace [1]. Good posting locations include employee break rooms, company bulletin boards, primary work areas, employee newsletters, and attachments to pay-slips. In the Volkswagen firm of Wolfsburg (Germany) or in the Town Council of Lausanne, each employee receives a written copy of the antiharassment policy document. At Mobistar, the Intranet informs employees and supervisors of current harassment policy [5].

Complaint Procedures

It is important managers create an environment in which employees feel comfortable in voicing issues of harassment. This requires designate persons to be established. Psychological harassment referents may be HR specialists (for example in Dupont de Nemours), other persons in the firm, or external persons. For example, the Town Council of Lausanne has designated internal voluntary employees. By contrast, Mobistar appeals to external expertise (a team Member Assistance Program) [5]. The work environment needs also to include mechanisms for facilitating grievance procedures such as established interview structures and complaint paper [5].

Recruitment and Selection

Recruitment and selection processes provide an opportunity for curtailing incivility [6]. HR managers in their recruiting and selection efforts can avoid the entrance of potential perpetrators. For example, interviewers can ask candidates to talk about their previous job, their good and bad work experiences, and relationships with supervisors, peers and subordinates. HR personnel should also spend time validating behavioural references from previous employers. Broad role descriptions consisting of job and performance expectations should spell out non-tolerated work behaviours.

Training

Finally, all employees and managers need to receive training in psychological harassment policy. The training of HR managers, supervisors, employees, and psychological harassment referents ('Mr or Ms Psychological Harassment’) should reiterate the organisation's policy prohibiting harassment [1]. The training might cover different topics, such as:

a) Definitions of psychological harassment

b) Examples of psychological harassment cases

c) Definition of the process (antecedents, responses,effects)

d) The employer's policy

e) The responsibilities of managers and supervisors for enforcement

f) Use of role-plays, and

g) Use of post-training questionnaires.

The aim of the training might be to increase people's skills and help them to detect and manage psychological harassment cases argues this is best achieved by mixing management and staff in the same program, obtaining support from the highest levels of management, using only qualified trainers, and videotaping the training sessions[1,6,8].

Implications for Practice

The Duvin case study illustrates the dynamic, emotional and complex nature of psychological harassment. Mr Duvin, it seems, actively listened to Ms Rex’s complaint, involved relevant others in the investigation, and attempted to find a workable solution for Ms Rex. However, the outcomes of psychological harassment (i.e., Ms Rex continues to be harassed and is transferred to another department; Mr. Mache receives a written warning) suggest more could have been done to combat harassment if effective management and prevention processes had been in place. For instance, no anti harassment policy existed in the firm so Mr. Duvin could not counter the site director's arguments and his personal support for Mr. Mache, Mr. Duvin’s organizational position of reporting to the site director, a 'long-standing' supervisor and friend of Mr. Mache, also compounded the problem. Moreover, the lack of formal complaint procedures and training sessions made it difficult to challenge and discourage Mr. Mache’s behaviour.

Finally, there was little follow-up after the final remedial action was taken. Nothing was organized to solicit feedback from Ms Rex and Mr. Mache, no training was proposed to Mr. Mache, and no analysis of the determinants of psychological harassment was made. HR managers like Mr. Duvin might be more effective at combating psychological harassment when they utilize the proposed intervention tool and ask process (diagnostic) questions in a systematic manner. Intervening in such a way suggests the following implications for manager practice. First, an effective intervention assumes managers will investigate promptly the complaint that has been made (i.e., within 24 hours after a complaint is received). This implies investigators will establish all of the facts and come to a decision about whether the complaint is upheld, or not upheld, based on these facts [9]. To complete a systematic investigation process, the organization may choose to rely on internal resources or resort to external expertise. In the case of using internal resources, the investigator may mobilize different internal services as works representatives, union trade services, health services, mediation services, and direction services [10].

However, if the organization has little or no experience investigating bullying or harassment complaints, then an external investigator may be justified [11]. In the Duvin case, Mr Duvin mobilized internal resources. Perhaps an external investigator may have been more effective during the investigation in view of Mr. Mache’s supervisory position and personal relationship with the site director. The fact that an external specialist is able to dedicate time exclusively to an investigation may make the process more efficient and effective. Second, the diagnostic tool requires managers to attend to record keeping. Managers need to be meticulous in documenting investigation procedures and recording interview notes with the victim, the perpetrator, and witnesses identified by either of them [1]. Such records may be electronically stored and password protected in an 'investigation file' separate from employee's personnel files. A diary containing dates and detailed information on the process will also help substantiate the facts of the case in the event of an appeal or legal action [11]. In the Duvin case, no mention is made of an investigation file relating to Mr Mache’s behavior [12-25].

Such a file might have proved useful in countering the site director's argument that no 'written evidence of the behaviours and remarks brought forth by Ms Rex and her colleagues' existed. An investigation file would have formalized the harassment process and possibly convinced the site director to take notice of the gravity of Mr. Mache’s alleged behaviour. Indeed, if Mr. Duvin had made use of our proposed characteristics of harassment (repetition of the behaviour, nature of the behaviour, and focus on a target, and result of the behaviour) he would have been able to identify and name Mr. Mache’s behaviour as psychological. Third, the process tool compels managers to understand psychological harassment within the context of individual, organizational, and societal characteristics and effects. This context influences the decision to act as shown in the Duvin case. Mr. Duvin strives to assert the respect of the person as an important element of the firm’s culture [26-33].

However, the Site Director places more emphasis on the status, personality and performance of Mr. Mache - individual characteristics that are paramount in the final decision to give Mr. Mache a written warning. It would seem from this outcome the perceived performance of Mr. Mache is more important a factor than the well-being of individual employees in this organization. If this is indeed the case, Mr. Duvin needed to codify these elements of organization culture and use this document as the basis for designing a workable harassment management and prevention system. Fourth, the process tool compels managers to prevent new cases of psychological harassment. In the Duvin case, no prevention process was developed and hence repeated acts of unacceptable managerial behaviour continued. An effective harassment prevention process requires managers to establish 'zero-tolerance' policies prohibiting psychological harassment, to circulate these policies to all members of the organization, to provide training in psychological harassment for all managers and employees, and to establish formal procedures to allow employees to complain about psychological harassment [33-48].

Given existing budgetary responsibilities and the pressure to achieve results, line managers may find it easier to refer harassment complaints to the HR department and let them identify and characterize the alleged behaviour. However, the paper cautions against this approach. Managers should listen to victim's complaints and formally record the nature of the alleged behaviour before seeking external advice and support. Managers have a duty of care to their employees. As such, they should be aware of the nature of work relationships and factors in the immediate work environment that directly or indirectly influence harassment behavior [49-51].

Go to

Conclusion

The proposed intervention tool represents a useful guide for managers dealing with an employee's psychological harassment complaints. As a diagnostic device, it helps identify the nature of harassment behaviour and alerts managers to the importance of the situational context in determining the effects of harassment and the decision to act. However, these benefits can only be realized if managers have the time, the analytical and emotional competencies, and the necessary support from senior management to stand back and systematically analyze the situation. Managers cannot face the situation alone as the Duvin case has shown. They need the support of senior managers, works representatives, occupational physicians, and HR specialists. Combating psychological harassment in the workplace is a collective not an individual responsibility.

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Juniper Publishers-CellSonic Behandlung 23.10.2017 - 15.01.2018

Clinical Image

a) 67-year-old patient with PAD of the three-tier type bds,

b) Height: 180 cm, body weight: 84 kg,

c) 2017 recanalized A. fem. Sup. and a. pop,

d) Wound exists since 25.07.17,

e) General Medical Conditions: Lung Ca, Diabetes Mellitus, Hypertension, Apoplexy (Figures 1-5).

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Juniper Publishers-Histology and Biologic Characteristics of Breast Cancer in Elderly of Balinese Population

Abstract

Objective: The aim of this study is to evaluate the histology and biologic characteristics of breast cancers in older Balinese women (age >65 years).

Materials and Methods: This is a hospital-based analytic cross-sectional study. Data are obtained from the breast cancer registry of admitted patients in Sanglah General Hospital.

Results: A total of 1,045 cases of breast cancer among Balinese women were recorded during the period of 1997-2013, of which 75 (7.2%) were diagnosed in elderly. Infiltrating ductal carcinoma (IDC) was the most common histologic type (75.4%), followed by infiltrating lobular carcinoma (ILC, 4.3%), invasive carcinoma of no special type (4.2%), mucinous carcinoma (1.9%), medullary carcinoma (0.9%), and malignant phylloides tumor (0.8%). There was a significant difference in the rate of IDC (76.2% vs. 65.3%, p = 0.035) and invasive carcinoma of no special type (3.7% vs. 10.7%, p = 0.010), but not for ILC, mucinous carcinoma, medullary carcinoma, and malignant phylloides tumor. The rate for ER- positive, PR-positive, p53-positive, and HER2-positive, as well as the rate of Luminal A, Luminal B, over-expressed HER2, and Triple Negative breast cancer also did not differ significantly between younger and older patients.

Conclusion: The biologic characteristics of breast cancer differ between younger and older Balinese women in terms of histologic type but not for the expression of hormone receptors.

Keywords: Balinese; Breast cancer; Elderly; Histology; Immunohistochemistry

Abbreviations: SEER: Surveillance Epidemiology and End Results; ER: Estrogen Receptor; VEGF: Vascular Endothelial Growth Factor; PR: Progesterone Receptor; HER2: Human Epidermal Growth Factor Receptor-2; VEGF: Vascular Endothelial Growth Factor; IDC: Infiltrating ductal carcinoma

Introduction

Breast cancer is the most common cancer among women in both developed and developing countries. It is also the leading cause of cancer death in females. In the United States, there were more than 200,000 new cases of breast cancer and 40,000 deaths in 2005 [1]. Currently, the incidence of breast cancer in Indonesia is 26 per 100.000 populations [2]. Advance age is the most important risk factor for breast cancer. According to Surveillance Epidemiology and End Results (SEER) databases, 43% of breast cancer patients are aged 65 and older at diagnosis, and 58% aged 65 and older at the time of breast cancer-related death [1].

The general population of Indonesia is now aging. According to the data published by the Indonesian Ministry of Health, with the increase of life expectancy, the number of older population will be continuously increasing over the next decades. In 2000, the life expectancy for Indonesian is 64.5 years with 7.18% of the population are aged 60 years and older. The life expectancy increases to 69.43 years in 2010 (elderly population being 7.56% of total population) and to 69.55 years in 2011 (elderly population being 7.58% of total population) [3]. Therefore, elderly will represent an increasing cohort of patients with breast cancer in the future.

Although the number of elderly patients with breast cancer is increasing, knowledge about possible differences in the biology and clinical outcomes of breast cancer according to age is limited. The relative under-enrollment of elderly patients in clinical trials is an important factor contributing to this limited knowledge [4]. In spite of the paucity of data, age is considered to be an important determinant of therapy, and the pattern of care of breast cancer patients differs depending on age [5-7]. More information about the biology and clinical features of breast cancer is needed to support the different approaches to therapy in elderly patients. Several large reviews have reported that the biology of breast cancer differs according to age, with the elderly tend to have more favorable tumor biology [8,9]. However, little is known about the biology of breast cancer among older Indonesian women, particularly of Balinese ethnicity. The aim of this study is to evaluate the biologic characteristics of breast cancer among older Balinese women.

Materials and Methods

We use the breast cancer registry of Sanglah General Hospital as the source of our data. The registry is the largest hospital registry in Bali covering Balinese population in nine districts, including Denpasar, Badung, Tabanan, Negara, Gianyar, Bangli, Klungkung, Karangasem, and Buleleng. The registry also includes data from patients that reside outside the island of Bali since Sanglah General Hospital is the center of referral for East and West Nusa Tenggara region. Thus, we exclude patients who reside outside Bali. We got 1,045 cases of primary breast cancer diagnosed between the year of 1997 and 2013. Only 160 cases presented with hormone receptor status (ER, PR, HER2) and 128 cases presented with p53 staining since immunohistochemistry analysis was applied since 2004 and it was costly and not covered in insurance, so not every patient could afford the examination. Only tumor with histologic type of infiltrating ductal carcinoma present with grading (n=711). We defined elderly as those who are 65 years and older. Then, we describe the characteristics for histology and grading, hormone receptor (ER, PR, HER2, p53), and IHC classification (Luminal A, B, HER2-type, Triple negative) according to the age group (elderly vs. non-elderly breast cancer). We compare the rate for breast cancer characteristics among the elderly and non-elderly or younger women. We use Statistical Packages for Social Science (SPSS ver.16) to aid the statistical analysis. The rates for each characteristic within each group of age were presented within percentage. Chi-square (x2) or Fischer-Exact test was used to test for significance between 2 proportions.

Results

A total of 1,045 cases of breast cancer among Balinese women of various ages were recorded during the period of 1997-2013, of which 75 (7.2%) cases were attributed to elderly (age >65 years). The mean age was 45.35 ± 8.74 years among the younger women and 70.03±4.49 years among the older women (mean age ± SD). The biologic characteristics of all study population were presented in Table 1. Infiltrating ductal carcinoma (IDC) was the most common histologic type, followed by infiltrating lobular carcinoma, invasive carcinoma of no special type, mucinous carcinoma, medullary carcinoma, and malignant phylloides tumor. Luminal A was the most common type of breast cancer in this study population.

Elderly had a significantly lower rate of IDC but a higher rate of invasive carcinoma of no special type compared to younger patients. However, there was no significant difference in the rate of ILC, mucinous carcinoma, medullary carcinoma, and malignant phylloides tumor between older and younger patients. The rate of high grade IDC also did not differ significantly (Table 2). Although there was a tendency of the younger patients to had Table 2: Histologic type according to age group.a higher rate of positivity for the expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2), the results did not statistically significant. The rate of Luminal A, Luminal B, over-expressed HER2, and Triple Negative breast cancer also did not differ significantly between older and younger patients (Table 3).

*Fisher-Exact test.

Number of sample that presented with grading was 711, 665 in the younger group and 46 in the older group.

FE: Fischer-Exact test

Number of sample that presented with p53 staining was 128, 121 in the younger group and 7in the older group.

Discussion

Our results suggest that biologic characteristics of breast cancer in older Balinese women are different compared with the younger women. We found a statistically significant difference in the rate of certain histologic subtypes. Older women in our study had a lower rate of IDC but higher rate for invasive carcinoma of no special type. Although there was a tendency for higher rate of mucinous and lobular carcinoma (histologic subtype which are associated with more indolent growth and progression) among older women, these results were not statistically significant. For the expression of certain protein markers (ER, PR, HER2, p53) as well as immunohistochemistry profile, we found no statistically significant difference between older and younger women.

Several large epidemiologic studies involving thousands of patients in North America and Europe confirmed that the biology of breast cancer in elderly patients appears to be different than in young women, with different molecular markers and a slower, more-indolent pattern of growth and progression. In a study involving more than 3,200 patients in Europe and 800 patients from the Massachusetts General Hospital, various prognostic markers were compared according to age [8]. They found no significant association between age and histology (ductal vs. lobular) or tumor stage at diagnosis, although there were significant correlations between age and expression of hormone receptors. They found that estrogen receptor (ER) expression, a known biomarker of improved prognosis, correlated positively with age. ER positivity was observed in 40% of patients aged 40, in 60% of patients aged 60, and in more than 70% of patients aged 80 (p-value <0.001). HER-2 overexpression, a known poor prognostic indicator, correlated inversely with age, with 29% positivity in those younger than 40, 17% in those aged 40-60, 14% in those aged 60-70, and only 9% in those aged >70 years (p-value <0.001). No significant association between age and markers of angiogenesis or invasion, i.e. vascular endothelial growth factor (VEGF), cathepsin D, and uroplasminogen activator.

In a study involving 50,828 and 256,287 women with invasive breast cancer in the San Antonio Breast Cancer and SEER (Surveillance, Epidemiology, and End Results) databases in United States, biologic characteristics of breast cancer are more favorable in older women compared with the younger women[9]. In San Antonio database, the rate of positivity for estrogen receptors increased from 83% in patients 55-64 years old to 87% in patients 65-74 years old to 90% in patients 75-84 years old to 91% in patients ≥85 years old (p<.001). Older women had higher rate of tumors that were diploid, had a low S-phase fraction and normal p53, and were negative for epidermal growth factor receptor and c-erbB2 compared with the younger women. The SEER database also supported similar correlations between age and biologic characteristics [9]. However, in both San Antonio and SEER databases, they observed no statistically significant differences in histological subtype, although there was a trend toward more-lobular and mucinous types (which are associated with more-indolent disease).

However, many of the large studies investigating the biologic characteristics among older women use younger women (age < 60 years) as a control group. In our study, the mean age for the younger group was 45.35±8.74 years (mean±SD). Only few that investigates the correlation between increasing age and the tumor characteristics among the very old patients. In a study involving 49,616 women from SEER-Medicare data set, the investigator examine the tumor characteristics of women age 80 years or older (80-84, 85-89, and ≥90 years) with stage I/II breast cancer compared with younger women (age 67-79 years). They reported that tumor characteristics (i.e. histology, grade, hormone receptivity) were similar across age groups [10]. However, the youngest women in this study were older than most women included in other studies. This study suggested that it is possible that tumors present with more favorable characteristics with older age but beyond age 67 years, these differences are negligible[10]. Other studies have also demonstrated that there were no correlations between increasing age and hormone receptor positivity among women older than 70 years [11,12].

Our study population was of Balinese ethnicity, and therefore are Asians. Asians may have a different tumor characteristics compared to Caucasians or Africans. One study has reported that breast cancer characteristics indeed differ according to race and ethnicity [13]. They reported that relative to non-Hispanic white women, Asians women (Filipinos, Chinese, Koreans, Vietnamese, Indian/Pakistanis) who live in the United States have a greater risk of presenting with biologic characteristics that associated with a poorer prognosis. Asian women had 1.2- to 2.6-fold elevation in the risk of having either ER-negative or PR-negative tumor. Asian women also had 20-70% reductions in the risk of having lobular and/or ductal carcinoma (except for Indians/ Pakistanis). Among Filipino and Chinese women, there were even 1.3- to 3.4-fold increases in risk of mucinous carcinoma[13] .In a study involving 280 Chinese women with invasive breast cancer, it was reported that the immunohistochemical typing characteristics of the elderly and youths were different [14] .

Race/ethnicity may play a significant role to the expression of certain breast cancer phenotype. The role may be attributed to the difference in genetics and lifestyle among the races. We have known that nulliparity/late age at first live birth, early age at menarche, and higher body mass index have been associated with an increased risk of developing an ER-positive tumor, but a decreased risk of developing an ER-negative tumor [15-18]. There was a tendency for Balinese women to be married young and being multipara. Unfortunately, data about parity, age at menarche, body mass index, or other factors associated with the hormonal status are still lacking in our registry.

However, there are several limitations to our study. Our study is a hospital-based cross-sectional study that used data from a hospital registry. The number of elderly breast cancer in our registry is far smaller than the number of non-elderly breast cancer. The number of patients that present with result from immunohistochemistry analysis is even smaller since not every patient can afford the examination. On the other hand, we are not sure of how many percent of Balinese population are covered in our registry since our registry is a hospital registry that rely its data source solely from the admitted patients. Thus, Balinese women with breast cancer that are not admitted to Sanglah General Hospital will not be included in our registry. Our study population may be less representative to the general population of women with breast cancer. Further efforts to increase the number of sample are needed in the future study.

Conclusions

The biologic characteristics of breast cancer differ between younger and older Balinese women in terms of histologic type but not for the expression of hormone receptors. Future study involving a larger number of elderly diagnosed with breast cancer is needed to further understand the exact correlation between age and breast cancer characteristics among the elderly of Balinese population.

Acknowledgement

The authors present their thanks to Made Utari Rimayanti who kindly helped in spell-checking and grammar checking of the manuscript.

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serenavangstuff · 5 years ago

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Juniper Publishers-Health of Schools, as a Social and Pedagogical Problem

Abstract

The analysis showed that schoolchildren's health is a complex socio-pedagogical problem that the distribution among children of chronic diseases, diseases of the organs of the gastrointestinal tract, diseases of the endocrine system, respiratory viral infections must be sought in three interrelated constituents of their lifestyle (family, school, leisure) that the widespread distribution of children in various forms of posture violations is due to the fact that the school does not pay enough attention to conducting in the school day a variety of if cultural and recreational activities (fitness pause a moment to fitness classes, outdoor break, morning gymnastics etc).

Keywords: Health; Way of Life; Spheres of Life; Social Institute; Public Awareness; Leisure; Sociological Research; Education System

Introduction

In recent years, there has been an avalanche stream of information on the deterioration of the health of schoolchildren in periodicals and in scientific publications. There are objective and important prerequisites for this. Thus, over the past 10 years, the incidence among school-age children has increased by 26.8% [1]. Today, approximately 90% of schoolchildren have a deviation in the state of physical and mental health [2] the overall incidence among students of secondary schools in Ukraine reaches 64% - 71%. During the period of study at school, the number of students assigned to a special medical group is almost doubled [3]. In recent years, a high level of physical health has been found in only 0.32% of boys and girls, above the average 4.18%, the average 27%, below the average27% and the lowest 41.48%. The consequence of this situation was that in the existing informational space of schoolchildren's health is used as an integral indicator of public assessment of the effectiveness of the functioning of the school physical education system, which, as practice shows, is not able to provide the necessary level of physical health of children and young people. The urgent need to address the whole spectrum of health, educational and educational tasks in the field of physical education of the younger generation needs to rethink the basic principles of organizing the existing system of physical education and ascertaining the complex of the main factors on which the health of children and youth depends.

The Aim of the Study

Identification of socio-pedagogical factors that affect the health of children and young people and the main directions of solving the problem of schoolchildren's health.

Methods, Organization of Research

Was to analyze the materials published in the special literature, which examines the health of children and young people, as well as to summarize the results of relevant studies conducted by specialists of the problem scientific research laboratory of the Kharkiv State Academy of Physical Culture (KDAFK) (scientific research director VO Sutula).

Results of the Research and Their Discussion

The decline in the health of schoolchildren that has been observed recently, according to experts, is due to the lack of volume of their motor activity [4]. Some publications directly indicate the existence of a high correlation between the state of health of schoolchildren and the level of development of the majority of their physical qualities, which (the level of development of motor qualities) in its entirety is the result of the motor activity of students [5]. Without rejecting the above mentioned provisions in general (the increase in motor activity of pupils really improves the functioning of all systems of their body, which is the basis of their physical health), it should be noted, however, that the simple increase in the volume of motor activity of children, without regard to the specificity of the disease, definitely does not guarantee the improvement of their health. This conclusion is indirectly derived from the analysis of the statistics of the morbidity of young athletes, the total volume of motor activity which can be considered sufficient if it is evaluated from the stand point of valid sanitary-and-hygienic norms. The results of this analysis show that among children and adolescents who are actively engaged in sports, in recent years there is a steady tendency of growth of various diseases [6,7]. Consequently, an increase in the volume of motor activity of children and young people does not automatically guarantee improvement of their health. Obviously there are other no less important factors that affect their health.

According to the definition of the World Health Organization, human health is characterized as a state of complete physical, spiritual and social well-being, and not only the absence of diseases or physical defects. It is obvious that this understanding of health is quite general in nature. It covers virtually all aspects of human life. Perhaps not by chance, experts point out that human health is 53% depending on the way of life, 21% from the environmental situation, 16% from hereditary factors, and 10% from medicine [8]. Consequently, it can be argued with high probability that the determining factor on which human health depends is a way of life. The mode of human life in the most general form is determined by the social role it performs in the three main spheres of life in the family, in the field of education (or work), in the field of leisure. From the above basic areas of social activity, the family institution plays a leading role in shaping the way of life of a child, because it is the family that determines the cultural and everyday environment in which the child is brought up.

To a certain extent, under the influence of a family of children, a need-motivational sphere is formed which, in fact, determines the nature of their relationship with others, as well as the main directions of the child's activities, including the use of physical exercises for their own health and physical development . The social status and financial status of parents determine the essential conditions of life of children the conditions of their residence, the quality of food, the possibilities of rest, the forms of spending their leisure time (visits to theaters, museums, palaces and houses of children's creativity, stations of young technicians, classes in sports sections and etc.), their level of medical support, and so on. The place of residence of the family determines the impact on the child of the environmental conditions, of which, as already noted, the health of a person depends on 21%. It is from parents that the influence of hereditary factors on the health of the child depends on which of 16% determines her health. Despite the important role played by parents in organizing the lifestyle of a child, the possibilities of a modern Ukrainian family to solve the problem of ensuring decent living conditions of children are quite limited, because today, as statistics show, 38.2% of the population of Ukraine is outside the subsistence minimum [9].

The second important component ofthe way of life of children and young people, which significantly affects their health, is the form of their leisure. Special investigations of this problem by the State Institute for Family and Youth Development show that only 44% of children between the ages of 14 and 17 have the opportunity to meet their leisure needs at an adequate level. For the majority of children, these funds are not enough to meet these needs (70%), free time (26%) and corresponding facilities at their place of residence (26%). Materials of these studies also point to the non-formation, as a whole, children have the right needs, because 14% of them never went in for sports, 34% did not attend circles, 24% did not attend theaters and museums; most of the free time children gave television programs, and every third teenager computer games. The national report on the implementation by Ukraine of the provisions of the UN Convention on the Rights of the Child [10] explicitly states that the main reason that adversely affects the organization of children's leisure is the lack of a sufficiently developed network of physical culture and sports, culture and recreation, as well as the poverty of families with children.

Perhaps these factors have contributed to the fact those in recent years the possibility of having children with healthy physical activity, which is a guarantee of their physical health, has narrowed considerably. The lack of real opportunities for children to undertake such leisure activities, as well as their lack of proper needs, leads to the fact that a significant part of children in their free time prefer to communicate with their friends. Currently, it is this environment that most influences the appearance of bad habits among children, as evidenced by the results of an analysis of the causes that cause the spread of tobacco smoking habits and alcohol consumption by young scientists in the KDAFK problem research laboratory [1113]. The materials of these studies indicate that every third schoolboy of secondary and senior school years already had experience in smoking tobacco, and in the seventeen years every fifth student of secondary schools was smoking. During the years of studying in school, the number of students who have tasted some or other alcoholic beverages increases. For example, in the 5th grade, every fifth (!) Student was drinking alcohol, and in the 11th grade of such students already about 70%. The identified trends in the prevalence of bad habits among schoolchildren (tobacco use and alcohol use) are fairly objective in nature. In general, they are confirmed by the results of special sociological studies conducted within the framework of the program "Health and Behavioral Orientation of Student Youth" [14]. Attention is drawn to the fact that in the process of studying in the school there is a pronounced tendency to increase the number of students who are indifferent to the widespread use of adult eating habits and alcohol consumption. The results of special sociological studies indicate that at present fifth grade of such students is about 15%, in the eighth about 35%, and in the eleventh - more than 50%. The given data indicate that during the years of studying in children, the active citizenship position on this issue is practically not formed.

Of the above three main areas of life children play a special role in organizing their way of life, the school, which is the main social institution, through which the process of transferring culture from one generation to another, within which the development of the personality of the child passes. It is at school that the outlook of the children is formed, their liveliness, and activity, independence, and organization, ability to work in a team, mutual help and other features of the character, which just determine the essence of the individual. It is at school that the children receive the necessary knowledge, skills and skills to help them choose their future activities. It is precisely in the school that is prescribed and regulated, through the use of various physical culture and recreational activities, the mode of motor activity of children during the day that is the basis of their physical health. Solving these tasks requires the creation of a special cultural environment in the school in which every participant of this process (student and teacher) should feel psychologically comfortable, be socially protected and in demand from others. It is obvious that the creation of such an atmosphere in school is a rather difficult task, especially in today's conditions, when all the traditional system of education is located, according to I Prokopenko and V Evdokimova [15], in a state of "stagnation and even crisis". As a result of complex processes that unfold in the system of school education, the fact that around 50% of students in general education institutions are weary of classes, about 40% of students is difficult to study, 25% of students consider the pupils' environment to be psychologically not comfortable, in 20% of students formed the feeling of not perceiving them from the side of teachers as individuals, and in 15% of them - a sense of unfair treatment of teachers.

Undoubtedly, the situation prevailing in the system of traditional education imprinted on the whole system of school physical education, since the latter is an integral part of it. At the same time, it should be noted that at present, in the development of the system of physical education of students of general education institutions, despite all the complexities, and positive trends exist. Thus, sociological researches carried out by KDAFK scientists have shown, firstly, that at present society is aware of the necessity and importance of a healthy and physically active lifestyle as one of the basic factors influencing human health; Secondly, among teachers and parents there is an understanding and concern about the negative trends that are manifested in the development of the system of physical education for students of general education institutions, in which the majority of parents (94.6%), which should be especially noted, are ready to take a possible participation in the process of its reform; Thirdly, the vast majority of students have a positive attitude toward physical education lessons (87.3%), and for 76.4% of them, such lessons are only satisfying. The above results of researches testify that at present in the system of school physical education there are positive prerequisites for solving, on a qualitatively new level, the whole complex of health-improving, educational and educational tasks. Some approaches to solving educational and educational tasks have already been presented in a previous publication. In this article, taking into account its purpose, we will pay attention to possible approaches to solving health problems. To objectivism this analysis it is necessary to consider, at least in the first approximation, the range of illnesses of schoolchildren.

If we proceed from the data published in the special literature, it should be noted that over the years of schooling almost twice the number of children with chronic diseases increases, in the last years up to 6-7 times a year the number of respiratory and viral infections has increased, the incidence of organs of the gastrointestinal tract in schoolchildren increased almost by 1.4 times, the endocrine system by 2.6 times. Sufficiently widespread in the environment of children marked diseases is due, as experts say, the state of their immune system, the influence on their organism of genetic factors and environmental factors, that is, the influence of factors that are determined by environmental, biosocial and psycho-emotional causes, and therefore lie in the plane of the three main components of the way of life of children (the family, school, leisure). Consequently, we can conclude that there is no direct cause-and-effect relationship between the occurrence of children with the above diseases and the volume of their motor Activity, which depends, first of all, on the peculiarities of constructing the pedagogical process in the system of physical education. That is why the increase in the number of such diseases among children cannot be a measure of the effectiveness of the functioning of the physical education system.

In the spectrum of diseases of schoolchildren, as shown by literary data, the determining place occupies various forms of violation of their posture. At present, the number of children with posture disorders is 80% 90% of the total number of students, and for the period of schooling, the frequency of manifestations of this disease increases by 1.5 times Violations of posture, as evidenced by the results of special studies, leads to a change in the relative position of the internal organs, which is accompanied by a violation of their normal activities (especially the lungs and heart), which adversely affects the functioning of all organs and makes the body of the child as a whole prone to various diseases. That is why we can say that posture is not a disease in its classical sense. It is likely to represent a "delayed action" that creates the preconditions for the emergence of other diseases, and which "explodes" when the influence of negative factors on the child's organism (ecological, biosocial, psycho-emotional, and others) reaches a critical level. It is obvious that that for the prevention of posture disturbances among schoolchildren it is necessary to apply special complexes of physical exercises, or health systems, which enable from the very beginning of schooling to purposefully influence the causes that cause the emergence and development of this disease.

As the main reason for the disturbances of posture among schoolchildren, as evidenced by the study of hygienists, is due to the fact that about 85% of daytime schoolchildren are without movement (sitting), this may mean that the prevention of posture disturbances among schoolchildren is reduced to regular exercise in the school day, as the lessons of physical culture and what is needed emphasize especially various physical culture and recreation activities (morning gymnastics, physical culture pauses and physical exercises at lessons, mobile breaks), which perform not only preventive functions, but also stimulate the mental performance of students. That is, the mechanism for preventing the disturbances of posture among pupils is based on well-known events, the need for which is regulated by the relevant orders of the Ministry of Education and Science of Ukraine, and which, unfortunately, is still paid insufficient attention in the system of general secondary education, as evidenced by the above statistics of manifestations of this disease. The importance and necessity of taking effective measures to prevent the disturbances of posture among schoolchildren, which is definitely one of the main health problems of the system of physical education, is understood at the state level. It is no coincidence that in the last year adopted a program for general education institutions to content training material in grades 5-9 introduces topics related to the prevention of violations of posture students.

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Juniper Publishers-Suicide in Patients with Dementia

Short Communication

Suicide is a major public health issue in many industrialized countries. It is one of the top ten causes of death and older age is a significant risk factor for suicide. For example, in Japan older adults (age ≥ 65) shared about 18.5% of total population but account for 24% of all suicide, in Taiwan, older adults representing 12.4% of the total population and account for 28.9% of suicide death. Suicide rate exponentially increases with age and in many countries, more men than women die from suicide; for instance. But in China, it is shown that suicide rate is higher in women than men. However, the suicide rate among elderly is comparatively high in many Asian countries; for instance, South Korea had the highest suicide rate and above one-fourth suicides in the world occur in India and China [1].

Dementia is a broad term for a progressive deterioration in memory ability and other cognitive function, psychological behavior and ability to manage normal life. It is a common syndrome among elderly. Some types of dementia are Alzheimer's disease (AD), vascular dementia, front temporal dementia, and Lewy bodies and Parkinson's disease (PD). Some symptoms associated with dementia are: progressive and frequent memory loss, changes in personality, loss of language and communication skills, impaired judgment, learning and concentration difficulties, a decline in ability to perform routine works, etc. With the aging world, dementia patient is increasing with an alarming rate. It is affecting 46.8 million people worldwide, there are 7.7 million new cases every year and the number wills 131.5 million in 2050. In terms of the number of dementia patients, China ranks first in the world, accounting for nearly 20% of all dementia patients worldwide. By 2025, about 7.3 million people (1 in 5 people) over age 65 will have dementia in Japan. A study found that among common types of dementia, only Alzheimer's disease was a significant risk factor for suicidal ideation and 'wish to die’ [2]. AD (contributing 50%-75% of dementia cases) is progressive and degenerative; caused by abnormal deposits of protein in the brain. AD destroy the cells which control memory and mental function. Advancing age, family history with AD, Diabetes Mellitus, Depression, Obesity, Hypertension, Hear trauma, Alcohol consumption, etc. are statistically significant and more likely to develop AD. Not only AD, most disorders associated with dementia are progressive, degenerative and irreversible. Dementia is strongly associated with late-life depression. A number of studies have been suggested that the most significant risk factor for suicide is the psychiatric illness, particularly depression. It is found that 45% of dementia patients with 'major depression' and 12% with 'minor depression' had thoughts of suicide. But, the role of dementia independently for suicide is controversial [2]. It is reported that early stage dementia is a risk factor for suicide in later life [3]. The painful impact of dementia and the experience of cognitive decline can’t avoid fear. Dementia patients fear being diagnosed. Dementia sufferers do not bear the disease passively as a result of fear of diagnosing and fear of adjusting detests environments.

But the risk of suicide declines at higher stages of deterioration in executive function and increased supervision. Studies have shown that many people with dementia can adjust to despise situations, have more positive evaluation of their lives, are able to enjoy mental and physical activities, do not suffer as a result of the condition that they previously feared and up to 67% of them with mild to moderate dementia associated with a very good or good quality of life. It is shown from a study that 30% of patients with Alzheimer's disease had wished to die and 9% made suicide threats at least once weekly [1]. A study among older people in South Korea found that 14.6% of them wished to die, about 40% of those wanted to suicide had depressive disorders and 22% had dementia [1].

Parkinson’s disease is also a risk factor for suicide among elderly. Parkinson's disease is a progressive neurodegenerative disorder of the central nervous system which results from loss of neurotransmitter dopamine in the brain [4]. It is characterized by tremors, motor, cognitive, behavioral, speech impediment and other non-motor symptoms and it is account for 3% to 4% of all dementia cases. The Sub thalamic nucleus deep brain stimulation (STN DBS) is a well-established treatment for advanced Parkinson's disease. A meta-analysis of 11 epilepsy surgery studies reported that the suicide rate of patients with epilepsy after surgical treatment was 0.98% (24/2425) which is approximately 30 times higher than of the general population [5]. It is found from a large prospective multicenter study of 5025 patients undergoing STN DBS that the rate of completed suicide was 0.45% (24/5311) and attempted suicide was 0.9% (48/5311), which are also far higher than in the general population [4].

From these evidences, it can be concluded that suicide or suicidal ideation is associated with dementia (especially with early-stage AD and advanced PD). Although the suicide rate has been slightly declined since last decade, it will be a great concern in the aging world. Since about 19% of total elderly will live only in Asia by 2050, suicide in dementia patients will be major health issues in Asian countries. So, research on risk factors and prevalence of suicide in dementia should give more attention.

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Juniper publishers-Does Population Ageing Affect the Least Develope Country Like Nepal?

Short Communication

Aging is a global issue of importance in 21st century. Today many people are living longer than ever before. Increasing life expectancy and decline in fertility are very beneficial trends driving population aging around the world. For the country like Nepal whose life expectancy was around 54 years in 1991 is now [1] expected increased to 71 years in 2018. It shows that in every two years, average life expectance is increasing by one year in Nepal. Elderly population growth rate is quite higher than population growth rate in Nepal [1,2]. Previous study shows that majority of Nepalese elderly are living with their children [1-5]. In the Nepali culture, generally parents live with their children especially with son [6]. A study shows more than 80% live with their children and only 2.7% elderly were living with their daughters [1]. Children are also considered as insurance for old age because other social security system is not well developed in Nepal [2]. Number of youth going to abroad for employment and higher studies is increasing rapidly in the recent decades. Anecdotal information indicates that the effect of internal and out migration has significantly affected the life of elderly people [7].

So far there has not been any National level study carried out focusing the issues of elderly so far. It shows Nepal government has not given more priority to this group of population. When we talk about the age structure of population the proportion of elderly 65 years and above is around 5 percent and this is not a significant number to give priority when compared with children and other age group population. Most of the study carried out focusing the issues of elderly is small in sample size. These studies show that Nepalese elderly are suffering from different types of social and health problems. A study shows 59% elderly are suffering from at least one chronic health problem. Major health problems faced by Nepalese elderly were blood pressure (23.4%), diabetese (13.2),respiratory disease (12.8), arthritis (9.4), back pain (8.4 %) and heart disease (4.9) [8]. Further two third Nepali elderly were found suffering from some form of loneliness [5,6].

A study related to functional disability of elderly 60 years and older shows 8.7% (8.5% for men, 8.9% for women) had functional disability in at least one Activities of Daily Living (ADL) items, and 29.2% (21.8% for men, 37.2% for women) in at least one Instrumental Activities of Daily Living (IADL) items. The most common dysfunction among the five ADL items for men and women was bathing. When adults aged 65 years and above were considered, functional disability in ADL was 12.8% (12.3% for men, 13.3% for women) and IADL was 36.8% (26.0% for men, 50.0% for women) [9]. This is quite high compared to other countries, but it is difficult to compare due to different methodologies adopted to measure [8,9].

Recently, one study carried out by Chalise and Basnet in community living elderly shows the prevalence of elder abuse is 47.4% among community living elderly [3]. In Nepali culture, elderly generally prefer to stay with their children and living in old age home is not very common. But the number of old age homes is increasing recently in Nepal. There are about 1,500 elderly living in about 70 organizations registered all over Nepal at present [10]. One review study shows elderly abuse is a serious neglected issue in developing country [11] and a recent study shows that 58 percent of the respondents experienced at least one elder abuse before they arrived at the old age homes [12]. Further, study carried out in old age home shows, older adults residing in old age home have high depression rate. Prevalence of depression was 57.8%. Among them 46.7% had mild, 8.9% had moderate and 2.2% had severe depression [13]. Depression was found slightly lower in community living Rai ethnic elderly [14]. One recent study shows, Nepalese elderly who are forced to live in old age home due to their childrens’s migration to foreign countries are not very happy as they are missing their children very much [7]. In some community the proportion of women living alone was 11.6%, which is noteworthy for the Nepali culture [15]. It shows some change in living environment in the Nepal culture as well.

If we look the demographic situation of Nepal working age (15-64 years) population accounts 63% of the total population. There are only 5% elderly 65 years and older. Social security system for the elderly is not well developed. With the increased number of elderly population it will also create economic burden on health sector as well. Recently, number of youth going to foreign countries for labor work is increasing due to prevailing unemployment situation in the country. Some youth going to foreign countries for higher education in western countries have also started to settle down there. A recent study shows that Nepalese elderly are missing their children very much as there is no family member to take care of frail elderly [7].

Nepali society has many youth population but number of elderly is increasing rapidly. On the other hand country is poor and it has to invest more on infrastructure development. A major resource of country goes to children and woman. Elderly problems are fallen in the shadow by other priority issues in the poor countries like Nepal. In the coming days above research findings shows that elderly problem will be very chronic once number of elderly having ADLs limitation elderly increases and there will not children to take care ofthem. So, government should develop some appropriate policies how elderly can be involved in active ageing in the community as well as management of elderly in the local community using local resources.

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Juniper publishers-A Long-Term Care Hospital-Based, Novel, Cost-Effective Strategy to Reduce Central Line Associated Blood Stream Infections

Abstract

An innovative nurse-led initiative of central venous catheter (CVC) dressing maintenance in long-term acute care (LTAC) setting significantly reduced the organizational incidence of central line associated bloodstream infections (CLABSI). The initiative included limiting scheduled CVC dressing changes to a trained staff nurse dedicated to that task. The project demonstrated that the initiative reduced patient harm by eliminating CLABSI in LTAC patients and was cost effective.

Keywords: Central line associated blood stream infections; Long-term acute care; LTAC; CLABSI; Line maintenance

Abbreviations: LTAC: Long-Term Acute Care Hospitals; LTCH: Long-Term Care Hospitals; CVCs: Central Venous Catheters; CLABSI: Central Line Associated Bloodstream Infections; LOS: Length Of Stay; PICC : Peripherally Inserted Central Venous Catheters; CDC: Center for Diseases Control; NHSN: National Health Safety Network; DU: Device Utilization; CMI: Case Mix Index

Introduction

Long-term acute care hospitals (LTAC) serve clinically complex patients requiring extended medical and rehabilitative care [1]. LTAC hospitals also referred to as long-term care hospitals (LTCH), have patients with Central Venous Catheters (CVCs) akin to acute care patients for either long-term antibiotics or other chronic intravenous medications [2]. Therefore, they are at risk for Central Line Associated Bloodstream Infections (CLABSI) resulting in significantly increased mortality, mean Length Of Stay (LOS), readmissions to acute care hospitals and mean attributable costs [3,4]. Maintenance of CVCs is ever more important in LTAC due to prolonged need for CVC to administer long term intravenous medications. However, literature is scarce in studies focusing on prevention of CLABSI in LTAC population [5-8].

Use of dedicated specialized intravenous teams has been successful in some acute care hospitals but may not be feasible or cost effective in smaller settings such as LTAC hospitals [9].9 While dressing changes are an important aspect of CVC maintenance, there are variations in technique among nurses with a potential lapse in maintenance of sterility during dressing changes [10,11]. We sought to find a feasible and cost-effective intervention customizable to LTAC hospitals that achieves desirable patient safety outcome by limiting scheduled dressing changes to dedicated personnel thereby limiting the variation in technique. To our knowledge, this is the first study to have evaluated the effect of limiting scheduled dressing changes to trained personnel other than specialized IV teams dedicated to that task in the LTAC hospitals. This is also the first study to evaluate the effect of dedicating a trained staff nurse other than specialized IV team nurses for dressing changes on CLABSI incidence in any clinical setting.

Methods

Clinical Setting and Study Design

This study performed a retrospective data analysis in an 82-bed LTAC hospital using before-and-after comparisons. Institutional Review Board has deemed this study a non-human subjects research.

Study Period

The baseline period was July 2014 to September 2015. Intervention period was January 2016 to September 2016. Transition period was October 2015 to December 2015 (when we rolled out the intervention).

Study Participants

All LTAC patients with a central catheter in place during the study period were included in the study.

Protocols During Baseline Period

Trained physicians inserted single, double or triple lumen CVCs, which are coated with chlorhexidine/silver sulfadiazine. Vascular access nurses placed peripherally inserted central venous catheters (PICC). All central catheter insertions used maximum sterile barrier precautions. LTAC used TegadermTM chlorhexidine gluconate dressings. Staff nurses routinely changed dressings once a week or when dressings are not occlusive, intact or dry with the exception of gauze dressings that were uncommonly used for oozing sites and were routinely changed every 48 hours. Nurses scrubbed the hub prior to any line access per CDC guidelines.9 Physicians discontinued the central lines when no longer needed. All staff nurses received catheter maintenance training at their new hire orientation and on skills days that occurred on a yearly basis.

Intervention

All baseline period protocols were also followed during intervention period. The nurse educator trained one staff nurse on dressing change technique for this intervention. The staff nurse (intervention nurse) changed dressings on a weekly basis. All staff nurses continued to be trained at their new hire orientation and on skills days. When an impromptu change was needed because of a soiled or non-occlusive dressing, the bedside nurse changed the dressing.

Outcome Measures

We used Center for Diseases Control (CDC)/National Health Safety Network (NHSN) definitions for CLABSI surveillance [3]. Outcome measures were CLABSI incidence rate per 1000 central line days and device utilization ratio. Device utilization (DU) was calculated as a ratio of device days (central line days) to patient days. The case mix index (CMI) is an economic surrogate marker used to describe the average morbidity of patients in hospitals [12]. We compared the CMI during the baseline period and intervention period to evaluate if there was a change in morbidity in the LTAC patient population during the two periods that might otherwise explain the changes in CLABSI incidence and DU.

Cost Estimates

CLABSI Costs: Costs for CLABSIs were obtained from previous research in LTAC hospital residents [4]. A mean attributable cost of $43,208 for a single CLABSI was used for cost analysis.

RN Wages/Benefits: We obtained data on RN wages from the Bureau of Labor and Statistics FY 2016. Since these wages are without benefits, we conducted additional analyses using a benefit estimate of 25.6% from previously published literature [13].

Statistical Analysis: Statistical analyses were performed using R version 3.3.0.28. We used two-tailed t-tests to examine the difference in mean (± standard deviation) CLABSI rate, DU ratio and CMI between baseline and intervention groups. Statistical significance was determined at a P value of 0.05.

Results

We evaluated a total of 21,770 central line days and 35,732 patient days during the entire study period.

CLABSI Incidence Rate, Catheter Utilization and Case Mix Index

As shown in Table 1, mean CLABSI rate significantly decreased from 0.87 ± 1.2 per 1000 central line days in baseline period to 0.11 ± 0.34 per 1000 central line days (P = 0.034) in intervention period. Device (catheter) utilization ratio also decreased from 0.69 in baseline period to 0.52 in intervention period (P = 0.003) (Figure 1). There was no statistically significant difference in CMI in intervention period (1.17 ± 0.03) compared to baseline period (1.14 ± 0.06) (P = 0.21) (Table 1).

*Significant at P<0.05

SD = Standard Deviation

CLABSI Attributed Costs

Using the mean attributable cost for CLABSI ($43,208 per case) published in 2014 and methods previously used, we calculated the cost avoidance achieved by the intervention during the study period [13-15]. There were 15 CLABSI in baseline period of 15 months and there was one CLABSI in the intervention period. The expected number for intervention period was projected as seven CLABSI cases applying the rate from baseline period and actual central line days in intervention period. Therefore, we calculated that the number of CLABSI avoided over the intervention period as six cases with an avoided cost of $259,248. Based on data from Bureau of Labor Statistics and previously published studies, we calculated the cost of RN time involved during the intervention period as $41.33 per hour including the base wage and benefits. Calculating for 8 hours a week for the 9-month intervention period, the cost of RN time devoted to the intervention was $11,903. Therefore, we calculated the cost savings as $247,345 (Table 2).

Limitations

This study was conducted in a single LTAC hospital but we believe our findings are generalizable since our hospital is similar to most LTAC hospitals in the country. The intervention nurse did not perform impromptu dressing changes (unscheduled, as needed) and had to rely on staff nurses for those. Even though we do not have data on how many impromptu dressing changes were performed, the significant decrease in CLABSI rate during the intervention period indicates that the collective intervention was effective. The training of nursing staff has not changed between baseline and intervention periods. However, it is possible that there was increased awareness among educators (trainers) during the intervention period and that could have affected nursing performance which we are not able to measure.However, one could argue that this effect, if it occurred, was desirable though unintended. Simultaneous decrease in DUR may also have played a role in reduced CLABSI. However, we believe this decrease was also the result of increased awareness due to this intervention. We did not assess patient level data such as age and length of stay. However, we showed that there was no difference in CMI between the baseline and intervention periods.

Discussion

Literature addressing CLABSI reduction with strategies specifically applicable to LTAC hospitals is scarce. Attention to dressing maintenance is even more important in LTAC hospital setting where patients have long stays with CVC in place for prolonged durations. However, ensuring adherence can be a challenge especially with increasing patient care demands on nursing. Utilization of intravenous therapy teams dedicated to dressing maintenance has been described in acute care literature [11,16,17]. We created and validated an effective strategy that specifically addressed the challenge of limiting variability in dressing maintenance in LTAC hospitals while avoiding the burden of increased costs related to specialized IV care teams which is neither feasible nor practical in these settings.

Our study has shown that limiting scheduled dressing changes to trained staff nurse/s dedicated to that task is associated with decreased CLABSI incidence in LTAC setting. Even though our CLABSI rate during baseline period was low, we had opportunity to improve our CLABSI rate even further with this intervention. This thought process is consistent with the culture of safety which asserts that one preventable complication is one too many. We could show a clear decrease in our CLABSI incidence to near-zero in intervention period. No other processes have changed between baseline period and intervention period. It is interesting that the device utilization ratio has also decreased during the intervention period despite not having any other simultaneous intervention to reduce device utilization. We believe this was due to an increased awareness towards CLABSI prevention due to mere introduction of the study intervention.

Hiring or allotting FTE to dedicated tasks such as this may be considered a hindrance from the standpoint of cost. However, we showed that having dedicated staff for central line dressing changes is very cost effective with avoided cost of CLABSI being much higher than the RN time required to perform the intervention. A detailed business plan explaining the cost effectiveness of this approach to hospital administration may be effective in getting the needed support for such an intervention. This approach could be an alternative to having a dedicated IV team for central line maintenance when having such a team is not feasible either due to financial constraints or due to small size of the healthcare setting.

Our study has much strength. First, to our knowledge, this is the only study to have assessed the strategy of dedicating a trained staff nurse that is not part of intravenous therapy team for CVC dressing maintenance especially in LTAC hospital setting. Second, we were able to demonstrate that this approach is feasible and cost-effective. Third, this simple intervention can be easily adapted at any LTAC hospital.

Conclusions

In conclusion, we demonstrated the feasibility and cost- effectiveness of limiting scheduled CVC dressing changes to trained staff nurse/s dedicated to that task in LTAC hospital setting. We showed that this approach was successful in reducing CLABSI to near-zero. This strategy should be considered in LTAC settings to reduce CLABSI.

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serenavangstuff · 5 years ago

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Juniper publishers-Fundamental Causes in Illness and Health Behavior: A Cross-National Comparison of Young Adults in the US and Nepal

Abstract

Extensive research has examined the nature of stress and its relationship with social and health outcomes in industrialized nations. On the other hand, considerably less study has focused on the role of stress in the well-being of individuals living in developing nations, and almost no research has directly compared this relationship across developed and developing nations. Yet, fundamental sociological concepts, such as Durkheim's mechanical and organic solidarity, imply such an approach to fully understanding such social relationships. In this study, we compare the relationship between stress from the death of a parent and two indicators of well-being, substance use and mental health, in the United States and Nepal. Additionally, differences between urban and rural contexts are emphasized. US data come from the third wave of the National Longitudinal Survey of Adolescent Health (Add Health), a nationally representative survey of adolescents and young adults. Data from Nepal come from two sources, the Kathmandu Mental Health Survey and the Jiri Health Survey, which respectively represent urban and rural settings in this developing nation. Data from the US are consistent with most research in developed nations. Females have higher rates of depression whereas males have higher rates of substance use with stressors more strongly tied to these gendered outcomes. In Nepal, the relationship of gender and education on both being depressed and substance use is similar to that in the US. However, significant socioeconomic effects on substance use beyond education are noted in the US, whereas age plays a unique role across all outcomes in Nepal. Implications of these similarities/differences are discussed.

Introduction

More than two decades ago, Link and Phelan 1995 pointed out the emphasis on individualized health risk factors in epidemiological and social research and suggested that such focus was problematic for research and policy that aimed to equalize health disparities. Rather, they suggested that a focus on underlying social structural conditions, or "fundamental causes," of illness was necessary to ultimately understand and reduce inequality in health outcomes. Such fundamental causes, they argue, produce social and environmental contexts that lead to divergent health outcomes across a variety of diseases and disease mechanisms. Link and Phelan note that, if such underlying issues are ignored, individually-based interventions are likely to be ineffective [1]. To substantiate the veracity of the fundamental cause argument, it is necessary to demonstrate the consistency of a fundamental cause effect across a variety of social and/or temporal contexts that include a diversity of morbidity and mortality regimes and a variety of disease mechanisms behind that diversity. In Link and Phelan's 1995 original discussion, they propose socioeconomic status (SES) as a fundamental cause comparing diseases and disease mechanisms across historical contexts from the 19th through the 20th century in present-day developed nations (especially the U.S.).

The current study expands this literature in two ways. First, we explore the notion of fundamental causes comparatively by examining comparable health and health behavior measures in the U.S. and Nepal, thus exploring the fundamental cause argument across developed and developing contexts. To date, study of fundamental causes within a developing nation context has largely been ignored. Second, within Nepal, we similarly compare comparable health outcomes and health behaviors across very different urban and rural contexts, a comparison that is also scarce with the literature on fundamental causes of disease. Specifically, we compare the "fundamental" nature of SES as a causal factor associated with depression, smoking behavior, and alcohol consumption using data on young adults from the U.S., an urban (modernized) part of Nepal (Kathmandu), and a more traditional village (Jiri) in Nepal. If the fundamental cause argument holds, then the relationship between social structure (SES) and health risk should hold when comparing developed and developing societies and when comparing "modern" and traditional social life within developing countries. Indeed, given the substantial economic inequality found in the U.S. context compared to the more limited range of economic differences across statuses in the economically disadvantaged Nepali contexts (i.e., the "floor" effect of absolute poverty that affects the Nepali economic distribution across SES statuses), results consistent with fundamental cause arguments should be interpreted as significant evidence in support of this thesis.

Fundamental Causes of Disease

Since Link and Phelan's 1995 original work proposing the fundamental cause argument, a growing literature has emerged around this concept. This work has generally tested the fundamental cause argument in three ways: Further refinement of the theory itself (especially pertaining to clarifying how SES is a fundamental cause); Applying the theory across different illnesses; Applying the theory in cross-national comparisons. Much of the refinement of the fundamental cause argument has been conducted by Link, Phelan, and their colleagues [2]. This work predominantly expands on the original proposition published in the medical sociology literature and extends that argument into related fields such as public health and gerontology. Additionally, a debate regarding whether SES is truly a fundamental cause or merely part of a spurious relationship explained by intelligence as the true underlying fundamental factor in health disparities has begun [3]. Furthermore, recent work has begun to discuss the interconnections of SES with gender and race inequality within the framework of the fundamental cause thesis [4]. Notably, when this theory- building work has employed supporting empirical data analysis, such data have come almost exclusive from the U.S. context.

While work refining the fundamental cause argument has been ongoing, other research has focused on demonstrating the validity of the thesis across various diseases and other health markers. Such work has shown support for the fundamental cause thesis when looking at cancer, HIV/AIDS, cholesterol levels, and mortality [5]. Similarly, work in this area has also used almost exclusively data from the United States, though some have noted the need for more testing of the thesis across contexts with different social and economic structures.

In response to this need, a handful of studies have begun to look at the fundamental cause argument comparatively. In such work, examined the fundamental cause thesis comparing the U.S. and Iceland, observing similar, though weaker, SES effects on health in Iceland compared to the U.S [6]. The effectiveness of the more progressive welfare state in Iceland is proposed as a possible explanation for this difference. Mc Donough et al.[7] show similar findings comparing the U.S. and U.K, and also suggest that the steeper SES-to-health gradient observed in the U.S. might be due to the effects of more comprehensive social policy in the U.K. Willsons et al. [8] findings when comparing the U.S. with Canada, however, are more problematic for the fundamental cause argument. Though low SES is associated with higher odds of preventable illness in the U.S. context, the Canadian results show no SES effect. Willson suggests that these results are still consistent with the fundamental cause thesis noting that less overall SES inequality in Canada than the U.S. coupled with more comprehensive social policies could explain the lack of SES results in the Canadian context. Why such findings are much more prominent in Canada compared to the results from studies in Iceland and the U.K., however, remains to be explained.

More importantly, perhaps, this limited set of comparative work has compared the U.S. to similarly industrialized nations that are among the wealthiest nations, even among developed nations. The lack of a comparison of the fundamental cause argument between developed nations and developing nations is notable. The universal claim of the fundamental cause argument should hold across societies that are organized in radically different ways even though the social and cultural meaning of status differences varies substantially. Since the core of the fundamental cause argument is differential access to resources based on differential location within a social structure and the major difference between developed and developing countries is the absolute level of resources, it is important to evaluate exactly how universal (fundamental) this social explanation for health inequality may be in light of such differences.

Indeed, Olafsdottir's et al. [9] results in comparing Iceland and the U.S. exemplify the strengths and weaknesses of the current research literature. The comparison of similarly wealthy nations with radically different welfare state mechanisms that address social status inequalities in very different manners and with substantially varying comprehensiveness allows for a particularly effective assessment of the fundamental cause thesis by focusing on the potential effects of the magnitude of inequality. Yet, research in such developed contexts offers little variety in the actual structure of different statuses and the relationships of those statuses to larger social institutions (e.g., both Iceland and the U.S. have similar occupational groupings oriented within relatively comparable post-industrial economies). By looking at developing contexts, such as Nepal, a more extensive assessment of fundamental causes is possible given that 1) such contexts offer similarly compressed economic inequality (i.e., the absolute poverty found in such contexts mimics in many ways the compressed inequality found in nations with more comprehensive welfare states such as Iceland-that is, even the relatively more economically well off in developing contexts are often not as disparate from their less fortunate peers compared to the heightened inequality found in liberal welfare state settings such as the U.S.) and 2) that the economic system and social statuses within that system are markedly different from those found in developed nations [10,11].

At the same time, non-developed countries are, in fact, developing. They are generally making a transition from traditional, relatively simple agro-pastoral economic and "mechanical" social relationships to more industrial/postindustrial economic and interdependent social relationships. This implies that the economic and social bases that create differential access to resources may also be undergoing changes within such nations. Perhaps the clearest way this can be observed in developing countries is through the differences between rural and urban settings that typically reflect the difference between traditional social relations and ones in the process of industrializing [12].

Developed vs. Developing Nations (U.S. vs. Nepal)

The magnitude of the difference in the wealth of Nepal and the U.S. is very easy to specify. The per capita Gross Domestic Product in 2000 for Nepal was $1,224 while in the U.S. it was $34, 677. The U.S., of course, is the quintessential example of a developed country while Nepal is one of the least economically developed countries in the world. The difference in wealth between these societies is also reflected in the quality of health and in the specifics of health risks. In comparison to the United States, the health of the Nepalese is very poor [13]. Life expectancy at birth in Nepal is about 65 years compared to nearly 80 years in the U.S. Until relatively recently, Nepal was one of the few countries in the world where males outlived females, due mainly to high rates of mortality in childbirth, and even now female life expectancy exceeds male life expectancy by less than 3 years. Infant mortality in Nepal ranges from 100115 per thousand births compared to 7-9 per thousand in the U.S. Despite these statistics, the annual population growth rate in Nepal is 2.4% compared to 1.1 % in the U.S., and the fertility rate in Nepal is 4.6 compared to 2.0 in the U.S WHO, 2001 [14].

The health problems in Nepal also differ from those in developed countries. Vitamin deficiencies and micronutrient- related disorders are widespread in Nepal [15]. Groundwater and well water contamination are significant problems. Food- borne illness is also a substantial source of illness in Nepal. Meat, in particular, is a prime source of food poisoning and the acquisition of parasites.

Urban vs. Rural (Kathmandu vs. Jiri in Nepal)

Within Nepal the illness burden differs between the urbanized area of Kathmandu and rural areas such as Jiri, which retains a largely traditional social structure. In part, the difference stems from the fact that fresh water and modern medical practice are scarce in rural areas like Jiri so that many easily controlled disorders such as parasitic and bacterial infections and respiratory ailments are common in Jiri but less prevalent in Kathmandu. Urban life exposes residents to different health risks. Smith reports, for example, that Sherpas living in Kathmandu have higher blood pressure than Sherpas living in the mountains. Urban dwelling Sherpas had higher BMIs and consumed more alcohol, which accounted for the differences in blood pressure and the elevated risk of chronic illness. There is also some evidence that psychological resources vary across the urban-rural divide, but mostly for women rather than for men [16].

Social Status and Access to Resources

The relationships between social status characteristics and exposure to risk or vulnerability to experienced risk appear to hold across urban and rural settings, but there is also reason to believe that the relationships are not identical across status groups. In traditional Nepal, for example, it is extremely rare for women to become educated and/or to generate independent economic assets (i.e., hold jobs). By contrast, in urban settings it is much more likely that a woman will become educated and that she will become economically self-sufficient or at least employed for pay. Economic development, as it is manifest in many urban areas, gives previously less-advantaged groups (such as women) better access to resources and, by the fundamental cause argument, may lead to comparatively better health. Thus, while differences in access to social resources between developed and less developed countries should be reflected in health differentials, one should also expect that differences in access to social resources between urban and rural areas of Nepal will be reflected in additional health differentials [17].

Although health risks differ as a function of the relative wealth of the U.S. and Nepal, there is reason to believe that social status differences operate similarly. Socio-economic status and gender affect illness rates in Nepal. Rous, Hotchkiss [18] reported that income has a direct effect on the likelihood of becoming ill in Nepal. Low social class is also associated with early marriage, complications in childbirth and maternal mortality, and women are generally at substantial risk of birth complications because 90% of births occur without skilled medical personnel present. In the United States, health inequality is often indexed in terms of class (education and income) and race. Americans who are poor, who have low education, and who belong to African American and Hispanic racial/ethnic groups have worse health. They have higher rates of both morbidity and mortality. However, health differences by gender are also observed, particularly with regard to psychological disorders. Women report more affective disorders while men report more substance abuse disorders. Although the U.S. and Nepal differ substantially in terms of the composition of the illness burden, that burden is distributed unequally in each society based on social status (particularly gender and class).

In the following analysis we make use of three data sets with common measures across U.S. and Nepalese societies and within Nepal to test the fundamental cause argument. We expect that health risk will vary by social status characteristics in both the U.S. and Nepal. We also expect health risk to differ between the urban and non-urban communities in Nepal. Unlike the developed contexts of Canada, Iceland, and the U.K. that have been compared to the U.S. in previous work, Nepalese social welfare policies are much less comprehensive than even those of the U.S. Thus, we do not expect to find weaker SES-to-health associations previously noted, although such a finding might not be surprising given the compression of most Nepali citizens into the lower portions of that nation's economic strata.

Data and Methods

Our data come from three sources. Data from the United States are taken from the public use files for the National Longitudinal Study of Adolescent Health (Add Health). Add Health is a school-based survey of health and health-related behaviors of adolescents in grades 7 through 12. The sampling frame included all high schools in the United States. A stratified, random sample from 80 clusters of schools was selected from this group. Over 90,000 students completed the in-school survey in 1994. Of those, a baseline sample of adolescents was interviewed at home between April and December 1995, between April and August 1996, and again between August 2001 and April 2002. The overall sample is representative of United States schools with respect to region of the country, urbanity, school type (e.g., public, parochial, private non-religious, military, etc.), ethnicity, and school size [19].

The Add Health data used here come from the third wave of in-home data collection in 2001-2002. Specifically, we examine the public use data which are a random sample of 50 percent of the Add Health Wave I core sample and 50 percent of the Add Health Wave I high education black sample. We restrict the analytic sample (n = 4,882) to the third data collection wave of Add Health (respondent ages 18 to 28 years) to achieve age comparability with the Nepali samples (described below). Data from Nepal come from two surveys. Urban data are taken from the Kathmandu Mental Health Survey; rural data come from the Jiri Health Survey. The target population for the Kathmandu Mental Health Survey is adults living in households in the Kathmandu, Nepal metropolitan area (this includes the municipalities of Kathmandu and Lalitpur). A preliminary list of households from the 2001 national census tabulated by the Central Bureau of Statistics (CBS) of Nepal was obtained in June, 2001. Although a simple random sample of households could have been drawn from the list, a two stage cluster sampling procedure was adopted. Kathmandu and Lalitpur are divided into administrative units called 'Wards'. Kathmandu has 35 wards and Lalitpur has 22 wards. Considering these 57 administrative wards as 57 clusters, 20 clusters were randomly selected with replacement using a probability proportional to household numbers in the clusters. A simple random sample of 250 households were taken from each cluster (i.e., ward) selected at the first stage. This resulted in 5000 households in the sample from 16 wards.

As the study was in progress, it was discovered that the sampling frame was faulty. It listed either more households or fewer households in certain wards than were actually present. In addition, about 10,000 households were missed by the CBS in its initial listing. This resulted in fewer households available for interview in certain wards reducing the total sample size obtained. Adjustments to data collection were made by repeating the process of randomly selecting wards but only using those ward numbers that were not selected with the faulty frame. Six new clusters (wards) from the new frame were chosen, and 250 households were chosen randomly from each drawing of a cluster. This process restored the sample to 5000 households. To reach age comparability with Wave III of the Add Health sample, data were reduced to only persons aged 18 to 29 years, resulting in an analytic sample of 1,052 respondents [20].

Data for the Jiri Health Survey were collected during a larger study of genetic risk factors for helminthic infection among the population of the Jiri Valley, in Eastern Nepal. The Jiri valley consists of a total of nine villages in the Dolakha District of Nepal. The region is 190 kilometers east of the capital city of Kathmandu. In general, the Jirels are subsistence farmers whose domestic economy is based on agro-pastoral production. The villages of Jiri have access to electricity and tap water, and a few houses have radios and television sets as well. All households in the area are listed in the project registry for the genetic risk factors health study. A simple random sample of 221 households (one in three) with approximately 1500 residents was drawn from the registry for this study. All individuals 18 years of age and above in these households were then enumerated and interviews were collected (n=426). To reach age comparability with Wave III of the Add Health sample, data were reduced to only persons aged 18 to 29 years, resulting in an analytic sample of about one-fifth of respondents (n=86) [21].

Measures

As in any comparative study, obtaining comparable measures across surveys and across national contexts is a difficult issue. When comparative work includes developing context, this task becomes even more problematic, and when rural contexts within a developing nation are examined, as in the current study, comparability of measures is nearly impossible. For the data used here, however, some comparable measures are available. Nevertheless, in order to examine the question of fundamental causes across these very diverse contexts, it has been necessary to adopt two compromising strategies. First, when possible, highly detailed measures in one or two of the datasets have been re-coded to match the lowest common component of that measure across all three surveys. Second, rather than focusing on a single health outcome with multiple SES predictors and control measures, the current study examines multiple health- related outcomes with a more limited set of predictors [22].

Depression

In the Jiri sample, only a dichotomous measure of whether a respondent has ever been depressed was collected. While the Kathmandu sample has somewhat more extensive measurement of depressive symptoms, we limit our measure here to a dichotomous measure of whether the respondent felt depressed 'most' or 'all' of the time over the last 30 days to maintain comparability with the Jiri data. Wave III of Add Health includes a balanced 10-item variant of the CES-D that has been shown to be consistent across gender. However, consistency across different ethnic groups for this scale is not well established which imply problematic application for cross-cultural comparisons. Such inconsistencies in the full scale across racial/ethnic groups have also been noted, but this research has shown that the depressed affect subscale within the CES-D is invariant across different ethnic groups within the US. We therefore use the four depressed affect scale items that are included in Wave III of Add health by summing them to create a 4-item scale (Individual items are coded on a three-point scale, from never or rarely (1) to most or all of the time (3) and refer to feelings the respondent had in the past week; scale values range from 0 to 16) and use a cutoff of 4 or more symptoms to create a dichotomous measure of being depressed to maintain a rough equivalence with the simpler measure available in the Jiri sample [23,24].

Smoking

Smoking in both the Jiri and Kathmandu samples is measured using a question that asks the respondent to identify themselves as 'never smoked', 'ex-smoker', or 'current smoker'. A dichotomous measure is created from these categories to indicate if the respondent ever smoked in order to achieve comparability with the U.S. data. In Add Health, respondents are asked whether they have ever smoked regularly at any point in their life for a period of at least 30 days [25].

Alcohol Consumption

Alcohol consumption is measured using an almost identical question across all three surveys that ask how frequently the respondent drank over the last 12 months. Responses are recoded into heavy drinkers (those who drank 3 days a week or more) with non-drinkers and those who drank on fewer than 3 days per week being the reference group [26].

SES

Education is measured as a dichotomous indicator of whether or not an individual has 12 or more years of education. Income status is measured as a dichotomous measure for high versus low income. An advantage in using the Nepali data for the purposes of the current study comes from the fact that income data have been adapted to U.S. dollar equivalents. That is equivalent currency is calculated in terms of value and not as a direct conversion of dollar to rupees in the survey documentation. For the U.S. data, we define low income as less than $12,000 per year to ensure that this category represents an income level at or near the poverty line. The equivalence data provided in the Kathmandu data documentation shows this to be equivalent to less than 60,000 rupees per year (i.e., 60,000 rupees per year is equivalent to about $12,000 a year in the context of Kathmandu, though the actual conversion rate would give a value of just under $900 U.S.). Because the rural areas of Nepal, like the Jiri area examined in the current study, are subject to substantially lower economic standards of living compared to the urban capital of Kathmandu, we use a suitably lower income threshold to indicate a near poverty level of less than 12,000 rupees per year.

Control Measures

Control measures include age, gender, and an indicator of the death of each parent. Age is measured in years. Gender is measured as a dichotomous indicator for being female. Death of each parent is asked separately in all three datasets and is included here as two separate indicator variables for the death of one's mother or father at any time. For the Add Health data, a parent is identified as the last person with whom the respondent co-resided that they identified as a parental figure. Death of a parent has been used as a standard predictor in stress events indices for adolescents and young adults, and in particular has been used successfully as a stress event predicting depressive symptoms with the Add Health Data [27,28].

Results

Table 1 shows the distribution of measures within each of the three datasets examined. Both the rural Nepal sample from the Jiri district and the nationally representative U.S. sample in Add Health are majority female, about 62% and 54% respectively. In the Kathmandu sample, however, men outnumber women by a small margin. Socioeconomic variables trend as one would expect with the poorest and least educated sample being from Jiri, the highest SES group being the Add Health sample, with Kathmandu falling in the middle. Indeed, in Jiri almost two-thirds of the sample can be considered low income with less than one-half obtaining 12 years of education. In the U.S. Add Health sample, on the other hand, less than half have low incomes and nearly nine in ten respondents have 12 or more years of education [29].

The prevalence of parental death across the three samples is similarly low with less than 2% experiencing the death of a father across all three samples. This low prevalence rate is mirrored for mothers' deaths in both Kathmandu and Add Health. However, the frequency of experiencing the death of a mother in the Jiri sample (7%) is more than three times higher than the rates in Kathmandu (0.3%) or Add Health (1.5%). This may reflect higher maternal birth-related mortality found more commonly in rural developing contexts. Because questions regarding smoking are asked somewhat differently in the Nepali and US datasets, descriptive frequencies are shown differently for the two countries. However, combining the percentages for 'current' and 'former' smokers in the Nepali data is relatively equivalent to the 'ever smoked regularly' question from Add Health. Doing so yields an ever smoked rate in Jiri of 17.5% and an ever smoked rate in Kathmandu of 18.5%. This is considerably lower than the Add Health ever smoked rate of almost 40%. Though one might expect age of onset differences to be important in explaining the lower Nepali percentages given the young adult nature of the data, the average age of first smoking is around 15 years across all three samples [30].

p<.10, *p<.05, **p<.01, ***p<.001.

“Father's death excluded from Jiri models due to small sample size.

Alcohol consumption varies considerably across the three samples. Heavy drinking is most common in Jiri (16.3%) where the prevalence is almost twice that found in Add Health and is more than seven times the rate found in Kathmandu. A possible explanation for higher drinking rates in rural Nepal compared to Kathmandu may lie in the level of religiosity of these areas. Rural areas in Nepal tend to be more religiously active, and since for some Nepali religious groups ceremonies frequently include the use of alcoholic beverages, rates of regular alcohol consumption as measured here may reflect these common practices. Table 2 through 4 shows the results of binary logistic modeling for all three samples on each of the three measures of interest: being depressed, smoking, and heavy drinking. For all measures, models with and without the effects of parental death are examined in Kathmandu due to limited experience of these events within this population (0.3%). For the same reason, father’s death is excluded from all models using the Jiri data (of the 86 respondents, only one reported the death of a father) [31]. Table 2 shows odds ratios for predictors of being depressed in each of the three samples. In both the Nepali samples, the likelihood of being depressed declines with age. While the results do not reflect this finding in the Add Health sample, a declining age trend during adolescence rather than young adulthood has been observed using Add Health. For both Nepali samples, age is the only statistically significant predictor.

In Add Health, however, gender, education, and father's death are significant predictors of being depressed. Consistent with the large literature on depression in the U.S. context, young women are considerably more likely to report being depressed than young men. Also consistent with U.S. literature on depression, having more education appears to be a protective factor against becoming depressed, and experiencing a significantly stressful event such as a father's death is associated with greater likelihood of reporting depressive feelings. Though not statistically significant, the odds ratios for education and parental deaths in the Nepali samples are in the same direction as those in the Add Health sample and are, therefore, suggestive of similar causal patterns across urban/rural and developing/ developed contexts consistent with the fundamental cause thesis. However, the pattern for gender is not consistent. While the non-significant odds ratio for women in the Jiri sample is very similar in direction and magnitude to that found in Add Health, the same odds ratios for the Kathmandu data are in the opposite direction suggesting that men may be more likely to report being depressed than women. Given the strength and persistence of gender findings in previous research on depression, the Kathmandu results (even if considered only as indicating no gender difference) deviate significantly from expected findings and require further explanation. We speculate that this may be because urban Kathmandu actually affords women greater opportunities for attainment than are true in rural areas and traditional Nepali culture. It may also be the case that men are under greater stress in Kathmandu because, while they retain a dominant gender position, they are also obligated to be successful in non-traditional economic activities that characterize the urban economy [32].

Table 3 shows the results for models predicting having ever smoked across the three samples. Results across both Nepali samples are remarkably consistent. In both Jiri and Kathmandu, being older is associated with greater likelihood of smoking, and being female is strongly associated with significantly lower likelihood of smoking compared to men. Higher education is also significantly associated with lower odds of smoking in Kathmandu, and although not statistically significant, the odds ratio in the Jiri results is consistent with this finding. Low income status and parental death do not appear to be associated with smoking in either Nepali sample.

p<.10, *p<.05, **p<.01, ***p<.001.

aFather's death excluded from Jiri models due to small sample size.

For the Add Health sample, reduced odds of smoking are similarly seen for women and persons with higher education level, which is consistent with the fundamental cause thesis. However, unlike in the Nepali data, age has no effect on the likelihood of smoking. Furthermore, having a low income appears to reduce the odds of smoking in the U.S. sample, a result opposite of that expected under a fundamental cause argument. However, this result may reflect the considerably higher costs of tobacco products in the U.S. context resulting from public health initiatives that create substantial taxes on tobacco products. In addition, the parental death stress events seem to be associated with elevated risk of smoking in the Add Health sample [33].

Table 4 shows models predicting heavy drinking across the Nepali and U.S. contexts. Results here are very similar to those in the models predicting ever smoking. Age is positively associated with heavy drinking in both Nepali locations, but has no effect in the Add Health sample. Across all three contexts, women are much less likely to be heavy drinkers than men. Greater education also appears as a protective factor against heavy drinking in both Nepali contexts, and although not statistically significant, the odds ratio for the U.S. results is in the same direction-a result consistent with the fundamental cause thesis. Although generally having low income does not appear to be associated with increased or reduced odds of heavy drinking, there is some suggestion that lower income results in slightly reduced odds of heavy drinking in the U.S.-again, perhaps reflecting elevated economic costs of alcohol in the U.S. versus Nepal due to taxation.

p<.10, *p<.05, **p<.01, ***p<.001.

aFather's death excluded from Jiri models due to small sample size.

Discussion and Conclusion

Over twenty years ago, Link and Phelan put forth the idea that social factors could be the fundamental causes of illness resulting in consistent findings of health disparities across historical and social contexts. Since then, additional research has supported the fundamental cause thesis across multiple health outcomes and in a handful of cross-national studies. In the current study, we have sought to extend this literature by investigating the fundamental cause argument in the context of one of the least developed nations, Nepal. Moreover, we were able to examine the contrast between the effects of status on health in urban and rural Nepal, which represents the contrast between modernizing and traditional forms of social organization frequently found within developing contexts.

Our findings generally support the fundamental cause thesis in the U.S. as well as in both the rural and urban Nepalese data. In particular, despite the fact that the types of common illnesses and disease mechanisms across these three contexts as well as the nature of social statuses vary considerably, evidence suggests that lower educated people in all three contexts are at greater risk of depression and may be more likely to engage in the risky health-related behaviors of smoking and frequent alcohol consumption. In other words, even in one of the least developed regions of the world, rural Nepal, less education is associated with poorer health. The consistent importance of gender in our analyses is also consistent with some recent work in the fundamental cause area.

On the other hand, the association of low income with poorer health and health behavior is not consistent across these three contexts, which does not support the notion of fundamental causes. However, this lack of effect may due to the nature of this type of SES measure. Income, in general, is a more volatile measure of SES than others such as education or wealth given its short-term orientation (e.g., annual salaries in developed nations), and it may have less predictive value given the potential for compressed income variation in poorer, agrarian contexts like Jiri. Furthermore, the erratic behavior of the income measure may be more pronounced in agrarian versus industrialized settings. For example, in an industrialized society, wages tend to be relatively similar across adjacent years given the incremental process of raises and promotions, with periods of unemployment causing some fluctuations. In an agrarian economy, however, year-to-year fluctuations in income can be caused by relatively common environmental issues (e.g., drought, cold weather, heat waves, etc.) resulting in considerably more volatility in any income measure. As such, wealth, or other similarly long-term SES measures such as education, are likely more reliable in the context of least developed nations. Thus, our income results should be viewed with some skepticism.

There are several important limitations of the current study. First, it would be ideal to have identical measures across all three contexts, especially more detailed measures of health outcomes than the simplified ones used here (e.g., full depressive symptoms scales). Additionally, a more extensive set of comparable covariates would be desirable. Unfortunately, the availability of comparably measured data that allow for quantitative comparisons of a developed nation and the rural and urban sectors of a developing nation are quite limited. Future data collection is needed for a fuller assessment of the fundamental cause argument across such contexts. Second, the current study is also limited in that longitudinal data are simply not available for the Nepalese contexts. A more complete test of the fundamental cause thesis should utilize longitudinal data (as others have done in developed nations), and future data collection in Nepal should build on previous work in order to allow for longitudinal analyses. Third, the sample size in the rural Jiri area of Nepal is quite small as might be expected for a relatively sparsely populated area, resulting in a pronounced lack of statistical power. While it is easy to suggest collecting a larger sample to solve such an issue, the migratory realities of developing nations where rapid urbanizing is ongoing probably mean that adequate sample sizes from rural areas of these nations will become ever increasingly difficult to obtain.

Despite these limitations, the contribution of the current findings lies in the diversity of contexts included. It is difficult to imagine social and economic contexts more different than the United States and rural Nepal. The former is among the wealthiest industrialized settings with widely available advanced medical treatment, exceptional variability in individual economic resources, and a health profile dominated by chronic disorders. The latter is among the least developed settings with an agro-pastorial economy and widespread communicable disease, but with little medical treatment available. That SES appears to be related to health and health behavior similarly across these contexts evinces clear support for the fundamental cause argument.

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serenavangstuff · 5 years ago

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Implementing Madrid Plan of Action on Ageing: What learnings in the last 15 years? What future directions?

Abbreviations

Abbreviations: MIPAA: Madrid International Plan of Action on Ageing; DHS: Demographic and Health Surveys; MICS: Multiple Indicator Cluster Survey; AAI: Active Ageing Index; ECE: Economic Commission for Europe

Short Communication

It's no secret that the world's population is aging. As fertility declines and life expectancy increases, the proportion of people in older ages is projected to grow in all regions of the world. Therefore, it is increasingly important to develop metrics that assess the effectiveness of policies and programmes affecting older people. The Madrid International Plan of Action on Ageing (MIPAA), developed in 2002, is central to this measurement agenda. It set out three priorities to guide countries in their policies:

a) Older persons and development (in particular

promoting social protection).

b) Advancing health and well-being into old age.

c) Ensuring enabling and supportive environments.

Fifteen years later, it is timely to assess the effectiveness of the Madrid Plan and indeed reviewing it is a theme of the next UN Commission for Social Development. The MIPAA started with great promise as one of the only international policy frameworks to focus on older people. The latest UN review of MIPAA shows that despite progress in policy formulations, its implementation remains uneven across countries and the three policy priority directions. Major constraints include lack of resources, political will and data.

So, what have we learned from the process? What do we need to do now?

The MIPAA experience so far offers one major lesson: its monitoring lacked a comprehensive global approach. This was partly because of lack of age-disaggregated data in many countries, but mainly for the fact that the MIPAA monitoring toolkit has not been properly developed. In such introspection, another critical question is: how MIPAA stays relevant when the international community is committed instead to its newest and most comprehensive policy framework to date, the 2030 Agenda of sustainable development.

MIPAA Monitoring Lacks a Comprehensive Global Approach

While progress is being made in the implementation of the MIPAA, there is no comprehensive global approach towards its monitoring. Metrics are an area that some feel was underdeveloped in the Plan. This in turn has led to a disproportionate submission of anecdotal, descriptive and self-defined information, with little evaluation of the relationship between outputs and policy impact. In particular, the limited use of indicators in national reporting has hampered comparisons of country-level progress. Such inconsistency and varied reporting is unsurprising in such a voluntary system. A specific example is on reporting progress towards sensitising and reducing elder abuse. Nordic and Western European countries introduced programmes that led to increased reporting and development of policies to prevent violence against older persons.

In contrast, very limited information is available in many Eastern European countries on the extent of violence, abuse and neglect of older persons. Even where data are available, cases are often underreported and prevention policies are lacking. Greater national capacities are needed: not only to design comprehensive policies for the older population but also to provide specific guidelines in assessing their progress. Detailed guidance on data collection, including timescales for reporting, is an area where investment will have significant impacts on the success of the MIPAA. This is even more important now that demographic aging has taken hold within developing as well as developed countries.

Lack of Age-Disaggregated data has been a Major Constraint

Fundamental to the successful implementation of the MIPAA is reliable country-level data collection and research, areas for which there was little guidance in the MIPAA's recommendations. In developing countries, the lack of data disaggregated by age and sex for even basic sociodemographic and health indicators is acute and makes tracking implementation of the MIPAA difficult. For example, in the majority of African countries, much of the available data are for younger age groups. Data that is especially important to older persons. It is not surprising that many African countries were not represented in Help Age International's Global Age Watch Index. Part of the problem lies in the fact that many surveys stop short of collecting data on older persons. USAID's Demographic and Health Surveys (DHS) and UNICEF's Multiple Indicator Cluster Survey (MICS) serve as two of the biggest tools for generating global statistics and they focus mainly on children and women under the age of 49. There could be the option of removing the age-cap in these existing global surveys, as has been done by South Africa.

However, a more desirable option will be that countries invest in collecting data using the specialised survey instruments and methodologies to collect data on older men and women. The new national survey on older persons in Iran, to be conducted during 2018, is a good practice example in this respect where policymaking communities in a resource-constrained country appreciate the value of high-quality evidence base on older people. The formation of the new UN Titchfield City Group on Ageing and Age-disaggregated data provides us a unique opportunity to ensure that countries learn from each other in the collection of age-disaggregated data and monitor progress in the implementation of the MIPAA.

The MIPAA Monitoring took it needs to be Developed

I believe an investment in global assessment tools is also vital to ensure that the MIPAA is implemented seriously. I suggest that a dashboard of indicators aligned with the key priorities of the MIPAA - including an adaptation of the Active Ageing Index (AAI) - should serve as the toolkit for monitor MIPAA implementation in the future. The composite AAI will help point to priority countries by comparing the index value. The dashboard of indicators can then help identify in which areas a country is doing well (or falling short) and what learnings can be drawn from the good global policy practices.

The AAI comprises 22 indicators, organised around four domains:

a) Employment;

b) Social Participation;

c) Independent, healthy and secure living and

d) Capacity and enabling environment for active ageing.

The AAI indicators are disaggregated by gender and in large part focus on people aged over 55. The AAI evidence can be summarised in an aggregated country-level score, facilitating global comparisons and the production of a league table. It identifies contexts in which older people fare better, and point to policy interventions that are effective in empowering older people and ensuring their rights. The AAI indicators was used by the UN Economic Commission for Europe (ECE) in the third cycle review of MIPAA, starting in 2015, to reflect the outcomes of ageing policies and to measure the untapped potential of older people. The latest AAI results for European countries show that Sweden, Norway, Switzerland and Iceland are at the top of the ranking, followed closely by Denmark, the Netherlands, Finland, the UK and Ireland.

Future Directions for MIPAA Implementation

I believe that the Sustainable Development Goals of the 2030 Agenda have put ageing back onto the international development agenda. The two pledges made, 'Leaving no one behind' and 'Reaching the furthest behind first', give us a strong momentum to seek inclusion of older people in all policymaking. We are therefore aspiring to live in a world in which no development process is complete without the objective of the promotion of quality of life of vulnerable groups of society, such as the older population, and where the older population's participation make them key contributors to the development process (Figure 1).

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serenavangstuff · 5 years ago

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Juniper Publishers-Sharing Older Adults Wisdom and Legacy through Digital Storytelling

Mini Review

Life stories told by older adults are a unique form of communication used to share wisdom acquired through the lifespan or to leave a legacy for family, friends and others. Wisdom has been defined as 'The quality of having experience, knowledge, and good judgement; the quality of being wise.' and 'the body of knowledge and experience that develops within a specified society or period' [1]. These definitions imply that one develops wisdom as one ages but this is not always the case in western culture that venerates youth more than old age. Yet in many cultures, wisdom is associated with old age and respected Huffington Post [2]. For example, in Greek culture, old age is honoured and celebrated and respect for elders is central to the family. In Korea, elders also are highly respected and in India, they are the head of the family. Finally, in many First Nations communities, elders are respected for their wisdom and life experiences and are expected to pass down their learning's to younger members ofthe community. For older adults, storytelling can be a valuable method to reflect upon life experiences and the lessons learned throughout their lives, i.e., the wisdom acquired. Moreover, a written story or a recording can serve as a legacy Birren, Deutchman [3]. Despite its dictionary definition. i.e., 'a gift or bequest of property, legacy can be considered as being as broad as the imprint of a life [4]. Older adults often express an interest in sharing their life experiences with their family and others. Their stories may be considered as a life legacy, so that older adults' family and other individuals might better understand them or learn through their life experiences Birren, Dutchman [3]. Older adults may feel that leaving a legacy is a way to keep their "presence" alive, even after death [5].

Digital Storytelling

Digital media provides a way to store, preserve, and share the digital legacies of older adults [6]. Digital storytelling extends the ancient practice of telling stories by using technology to combine text, images, music, narration, sound effects, and videos [7]. Storytellers create a narrative about their personal experience in the form of an easily shared compact multimedia artefact. The creative process used in digital storytelling could provide older adults with the means to capture and reflect on memories and lived experiences. Furthermore, digital stories may allow older adults to reach a large audience as they can be heard, viewed, and shared easily [8-10]. Digital stories can be shared publicly by uploading them to the Internet, saving them on a digital media device such as a flash drive, or showing them to others in public events.

Well-being of Older Adults

In recent years, there has been increased interest in the importance of the social and psychological well-being of older adults [11,12]. The act of sharing stories may bring various benefits to social and psychological well-being [3]. Suggest that sharing autobiographical narratives can have several positive effects for older adults such as increased self-esteem, a stronger identity, and finding increased meaning in their lives. A review by [13]. On reminiscence research, a process of recalling events in a persons' life, found that reminiscing had a moderate effect on life-satisfaction and well-being. In another example, Meléndez Moral et al. [14] conducted research on integrative reminiscence. In this style of reminiscence participants recall events and try to integrate past and present to form meaning. The results showed that reminiscence led to increased self-esteem, life satisfaction, and psychological well-being and reduced depression. Previous studies have shown that a lack of communication and social connection to others can contribute to isolation and loneliness which in turn can result in problems such as depression and cognitive decline for older adults [15,16]. It is important to provide opportunities where older adults can share their experiences, make connections, and build relationships with others in positive and supportive social environment. In leisure activities, designing for group interactions may help with such issues as reducing loneliness, increasing self-esteem through life-long learning opportunities, and increasing a feeling of social connectedness [17].

Digital Storytelling Course

We have been offering a ten-week digital storytelling course in venues such as community centres, senior centres, libraries, museums, and independent living facilities. The course is intended to give participants an opportunity to explore their life stories and create a digital artefact, so they can easily share a piece of wisdom or a legacy story from their life with course participants and others. The process requires participants to reflect on their past and choose a short story that represents a moment, event, or person in their life. This has some similarities to autobiographical narrative work and reminiscence research. The shared experience during the course of designing and digitizing personal stories may enhance well-being through increased social connectedness and self-understanding. The creation of digital stories is not done in isolation, but stories are created collaboratively and then shared with others at the conclusion in a "sharing our stories" event within the community. Thus far, we have collected more than 100 digital stories and have conducted research on the benefits of these courses in press [18].Our experience thus far has been encouraging. The benefits can be summarized by a quote from two of our participants, who stated: "I think that's what it is and you look at people and you meet them the first day and we're all strangers, but then, by the end of the time you, you know, these little bits about that person, that ah, it, it’s personal."(Female, late 60s). "I want to write something for my family, for my grandkids 'cause I don't get to see them very much. And they don’t know a lot about my side of my family, so I really wanted something to, really lasting memories."(Female,70s). We plan to continue offering the course and conducting research on its' impacts on participants. We have already offered the course to older adults with mild dementia, a First Nations community in northern Canada, and we are now planning courses for caregivers and intergenerational teams[19] .

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serenavangstuff · 5 years ago

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juniper publishers-Non-Pharmacologic VTE Prophylaxis in Elderly

Abstract

Dry Venous thromboembolism (VTE) includes deep venous thrombosis (DVT) and pulmonary embolism (PE) and is a significant potential health complication for hospitalised patients. Serious adverse outcomes may occur, including an increased risk of recurrent thrombosis, morbidity from post- thrombotic syndrome or death. The risk of developing VTE depends on the patient's background risk factors and upon the condition or procedure for which the patient is admitted. Effective prophylaxis will be achieved through assessment of risk factors and existing medical conditions with application of appropriate drug therapy and/or mechanical devices. This Standard guides the assessment of risks and strategies to reduce the risk of VTE with provision of VTE prophylaxis.

Assessing the benefit-risk ratio of anticoagulation is one of the most challenging issues in the individual elderly patient, patients at highest hemorrhagic risk often being those who would have the greatest benefit from anticoagulants. Some specific considerations are of utmost importance when using anticoagulants in the elderly to maximize safety of these treatments, including decreased renal function, co-morbidities and risk of falls, altered pharmacodynamics of anticoagulants especially VKAs, association with anti-platelet agents, patient education. To reduce the side effects of pharmacological agents and to increase the effectiveness of prophylaxis and treatment of DVT and PE, non-invasive method was introduced. The goal of this method is to achieve an augmentation of venous blood flow in lower limbs via external mechanical devices.

Introduction

The benefits of VTE prophylaxis often outweigh its risks, such as symptomatic DVT and PE, Fatal PE, costs of investigating symptomatic patients, risks and costs of treating unprevented VTE, increased future risk of recurrent VTE, and chronic post-thrombotic syndrome. There are various approaches in prophylaxis and management of DVT and PE that includes both pharmacological and non-pharmacological methods. Subcutaneous heparin (unfractionated or fractionated) may be the most effective means of prophylaxis. However, neurological injuries and major bleeding often preclude its use due to the increased risk of hemorrhagic complications. Non- pharmacological methods may be favorable for DVT and PE prophylaxis in such cases.

To assist in reducing risk of VTE, commence prophylaxis as early as possible during the patient's admission or commence as scheduled after immediate care and risk assessment is carried out. Emergency Department clinicians should commence risk assessment and prophylaxis when the patient will not be seen by the in-patient team/consultant until the next day. Risk assessment must be undertaken for both medical and surgical patients who have significantly reduced mobility for three days or longer or are expected to have ongoing reduced mobility relative to their normal state and have one or more risk factors. Patients must remain adequately hydrated and must be encouraged to mobilize as soon as possible and to continue being mobile post discharge [1].

Goal of VTE prophylaxis

The main goals of VTE prophylaxis are to stop a clot from forming or growing and to reduce the chance of another clot developing. VTE prophylaxistreatment focuses on the appropriate selection of pharmacological and non-pharmacological/ mechanical approaches, based on the individual patient's risk factors and type of surgery. One element of VTE prophylaxis is early ambulation following surgery. However, physician orders such as "ambulation as tolerated" generally do not result in sufficient activity and associated prophylaxis. Therefore, in addition to ambulation, VTE prophylaxis options, in most cases, need to include pharmacological and/or non-pharmacological/ mechanical options.

There are two types of prophylaxis, pharmacological and mechanical. The use for thromboprophylaxis has to consider several things, such as the height of VTE prevalence, adverse consequences of VTE, efficacy and effectiveness of thromboprophylaxis [2]. Some agents are contraindicated or require a reduction of dose in elderly patients or those with renal impairment. Prescribers should refer to current product information to select a safe dose for individual patients, taking care to select the dose recommended for prophylaxis and not the dose recommended for therapeutic anticoagulation. Many drugs, including anticoagulants (e.g. warfarin), anti-platelet agents, selective and non-selective non-steroidal anti-inflammatory drugs and antithrombotic agents may interact with prophylactic agents to increase the risk of bleeding. Decisions about appropriate concomitant use of these medications for VTE prophylaxis should be made on an individual patient basis in consultation with the Attending Medical Officer.

Where pharmacological prophylaxis is contraindicated, mechanical prophylaxis remains an option and should be considered, as indicated, until the patient is mobile. Patients having a risk ofbleeding must not be treated with pharmacological VTE prophylaxis [3]. Additional contraindications beyond bleeding risk may include:

a) Known hypersensitivity to agents used in pharmacological prophylaxis

b) History of, or current, heparin-induced thrombocytopenia

c) Creatinine clearance <30mL/minute

The following are non-pharmacological or mechanical options for VTE prophylaxis:

a) Graduated Compression Stockings (GCS) for ambulant patients or Thrombo Embolic

b) Deterrent Stockings (TEDS) for immobile patients.

c) Intermittent pneumatic compression (IPC) or foot impulse devices (FID)

d) Intravascular filtration

Graduated Compression Stockings and Compression Devices

For surgical patients, thromboembolic deterrent stockings (TEDs) with appropriate pharmacological prophylaxis are usually provided until the patient is fully mobile. If pharmacological prophylaxis is contraindicated, the most appropriate mechanical device available (e.g. intermittent pneumatic compression (IPC) or foot impulse devices (FID) should be used until the patient is mobile. All stockings must be fitted and worn correctly according to the manufacturer's recommendations. It should be noted that graduated compression stockings may increase the risk of falls in mobilizing patients. Patients should be instructed to wear appropriate non-slip footwear [4]. Stockings must be removed daily to assess skin condition and perfusion and to provide skin care. Active compression stocking gives higher pressure than passive compression stocking (16-22mmHg).

There are three different pressure level of compression stockings: moderate pressure (15-20 mmHg), strong compression (20-30 mmHg), and extra strong pressure (30-40 mmHg). Compression stocking can prevent thromboembolism in immobilized patients, repair lower limb vein blood flow, control the progressivity of vein and lymph disorders, and reduce the swelling. The compression level continuously decreasing from distal to proximal within the medically approved level of compression [5,6]. As conclusion, compression effectively prevents VTE due to the ability to increase the velocity of blood flow and reduced the static of vein (Figure 1).

Compression stockings may be contraindicated in patients with:

a) morbid obesity where correct fitting cannot be achieved

b) inflammatory conditions of the lower leg

c) severe peripheral arterial disease

d) Diabetic neuropathy (there is a risk of injury due to decreased sensation and discomfort if there is a problem with the fitting).

e) severe oedema of the legs

f) unusual leg deformity

g) allergy to stocking material

h) cardiac failure

IPC or FID can exacerbate lower limb ischemic disease and are contraindicated in patients with peripheral arterial disease or arterial ulcers.16 IPC is contraindicated in acute lower limb DVT [7].

Complications of Mechanical Prophylaxis

Incorrect fitting may result in bunching of the stockings resulting in leg ulceration, pressure ulcers, slipping and falling on mobilization.

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